EDD Assistance Form

First Name *

Last Name *

Address*

City/Town

State/Province

ZIP/Postal Code

Phone Number *

Your Email *

Do you have an EDD Customer Account Number (CAN)? *

CAN #(Make sure to include your CAN number provided by EDD) *

Date of Birth *

Date case first filed *

Last day of work *

Date of last payment *

Describe the Issue *

Type of Benefit (indicate which benefit you applied for) *

Reason given by EDD for interruption of benefit payments *

Have you certified for ALL weeks pending of benefits?*

Yes

Unsure

If no, which weeks have you certified for?

How many weeks of benefits are you owed? (Please answer as accurately as possible)*

Office Information