Select your zip code - None -90004900059000690007900109001290013900149001590017900189001990020900219002390026900299003390038900409005390055900579005890063900709007190075900769008190101902019025590270Other Assistance Form Contact Information Name First Middle Last Address Address Address 2 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 VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Address Date Applied for Claims What did you apply for? - Select -Unemployment Insurance (UI) Pandemic Unemployment Assistance (PUA)State Disability Insurance (SDI)Paid Family Leave (PDL) What is your issue? What is your issue? OtherID verificationWage verificationAppealsUnpaid benefits Pandemic Unemployment Assistance (PUA)Other… Enter other… Have you certified for ALL weeks pending of benefits? Yes No 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) Who have you contacted? Have you contacted another elected official? Yes No Comment [Optional] Disclaimer: Please do not send personal identifiable information 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 Santiago (the “Assemblymember”) 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. I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblymember’s office needs additional information, such as my EDD number, the office will contact me to request that information. By clicking here, I accept and agree to the terms in this form. Zip code entered is outside of the District. Please use the Find Your Rep webpage to find your District Representatives.