EDD Request for Assistance

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Select your zip code

Contact Information

First

Middle

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Email Address

Date Applied for Claims

What did you apply for?

What is your issue?

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)

When was the last time you received a correspondence from EDD (via mail, phone, or text)

Have you contacted another elected official?

Yes

Who have you contacted?

Comment [Optional]

Disclaimer

REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION. Please carefully read the following: By completing this form, I am requesting the Office of Assemblymember Chris Rogers to assist me in working with the Employment Development Department (EDD) on my claim. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize EDD and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved. Disclaimer: Please do not send any personal identifiable information through this form that is not specifically requested. If we need additional information, such as your EDD number, we will contact you to request that information.

By checking this box you agree to the disclaimer above

Zip code entered is outside of the District. Please use the Find Your Rep webpage to find your District Representatives.