EDD Assistance Form First Name * Last Name * Residential Street Address * Address* City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Number * Your Email * Do you have an EDD Customer Account Number (CAN)? * - Select -YesNo 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) * - Select -UnemploymentPUA (Pandemic Unemployment Assistance)PEUC (Pandemic Emergency Unemployment Compensation) Reason given by EDD for interruption of benefit payments * - Select -ID VerificationSuspected/Potential FraudDisqualifiedWebsite issueNeed to reopen caseNo benefits leftOther or no reason given by EDD Have you certified for ALL weeks pending of benefits?* Yes No Unsure If no, which weeks have you certified for? How many weeks of benefits are you owed? (Please answer as accurately as possible)* Leave this field blank