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EDD Assistance Form
First Name *
Last Name *
Residential Street Address *
Address
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ZIP/Postal Code
Phone Number *
Your Email *
Do you have an EDD Customer Account Number (CAN)?
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Yes
No
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) *
Unemployment
PUA (Pandemic Unemployment Assistance)
PEUC (Pandemic Emergency Unemployment Compensation)
FED-ED Extension
Not Sure
Reason given by EDD for interruption of benefit payments *
ID Verification
Suspected/Potential Fraud
Disqualified
Website issue
Need to reopen case
No benefits left
Other or no reason given by EDD
Additional for issues with EDD *
Payments Pending
File a new claim issue
Unable to Certify for Benefits
Extension Pending
Leave this field blank