DE 2523F Rev. (12-18) (INTRNET) Page 1 of 3 CU REPORT OF VOLUNTARY PLAN FAMILY LEAVE (VPFL) CLAIM PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM A.CLAIMANT INFORMATION (FAMILY MEMBER PROVIDING CARE) COMPLETE SECTION A, ITEMS 1 226 17 AND SUBMIT WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR PAID FAMILY LEAVE BENEFITS. (RETAIN A COPY OF COMPLETED SECTION A) 1. SOCIAL SECURITY NUMBER 226 226 2. CLAIMANT 222 S NAME ( FIRST , MIDDLE , LAST ) 3. CLAIM EFFECTIVE DATE 4. CLAIMANT 222 S MAILING ADDRESS 5. SEX MALE FEMALE 6. DATE OF BIRTH MM DD YYYY 7. VOLUNTARY PLAN NUMBER 226 8. VOLUNTARY PLAN EMPLOYER NAME 9 . CLAIMANT 222 S PHONE CLAIM INFORMATION 10. TYPE OF VPFL CLAIM (CHECK ONE): FAMILY CARE CLAIM CHILD BONDING IS THIS BONDING CLAIM RELATED TO AN SDI OR VP PREGNANCY CLAIM? YES UNKNOWN FAMILY CARE/BONDING RECIPIENT222S NAME (REQUIRED):FAMILY CARE/BONDING RECIPIENT222S DATE OF BIRTH (REQUIRED):13. 14. IF THE BONDING RECIPIENT IS A FOSTER OR ADOPTED CHILD, DATE OF PLACEMENT WITH THE CLAIMANT:DO YOU WANT STATE AWARD INFORMATION? NO YESIF 223YES,224 ENTER THE NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYER OR PLAN ADMINISTRATOR. Name: Address: 15. ( REQUIRED ) TYPE / PRINT NAME OF PERSON COMPLETING SECTION A 16. PHONE NUMBER 17. DATE FOR DEPARTMENT USE O NLY CLAIM EFFECTIVE DATE WEEKLY BENEFIT AMOUNT $ MAXIMUM BENEFIT AMOUNT $ B. WITHIN 35 DAYS AFTER FINAL PAYMENT FOR EACH FAMILY LEAVE PERIOD (ON RETAINED COPY), COMPLETE SECTION , ITEMS 18 226 28 AND SUBMIT. 18. VPFL WEEKLY BENEFIT AMOUNT $ 19. FIRST DAY PAID 20. LAST DAY PAID 21. NUMBER OF DAYSBENEFITS PAID 22. WERE ONE OR MORE DAYS PAID ATLESS THAN THE FULL DAILY RATE? 23. TOTAL AMOUNT OF BENEFITS PAID $ 24. TOTAL AMOUNT DIVERTED TOSATISFY SUPPORT OBLIGATION $ 2 5 . CLAIM STATUS ( CHECK ALL APPROPRIATE ) BENEFITS EXHAUSTED CLAIMANT RETURNED TO WORK BENEFITS DENIED (ATTACH DENIAL LETTER) RE-ESTABLISHED CLAIM ADJUSTMENT 26. ( REQUIRED ) TYPE OR PRINT NAME OF PERSON COMPLETING SECTION B 27. PHONE NUMBER 28. DATE CITY STREET/PO BOX STATE ZIP CODE American LegalNet, Inc. www.FormsWorkFlow.com DE 2523F Rev. (12-18) (INTRNET) Page 2 of 3 I NSTRUCTIONS FOR COMPLETING THE R EPORT OF V OLUNTARY P LAN F AMILY L EAVE C LAIM , DE 2523F Any missing information may result in returning the form and delaying the award information. Section A: Complete items 1-17 and return within 15 days after receipt of a first claim for VPFL benefits. (California Code of Regulations, title 22, section 3267-1). Submit to address below. Retain copy of completed Section A. Items 1-14, Information regarding the family care/child bonding provider and his/her family member. Enter all digits of VPFL claimant222s Social Security number (SSN). (A claim cannot be processed without an accurate SSN. Theuse of an incorrect SSN can result in erroneous notices to the claimant and employer.)Enter the VPFL claimant222s full name.Enter the claim effective date the VPFL claim began. This is the date the claimant has given as the first date he/she wantsbenefits to begin.Enter the VPFL claimant222s current mailing address.Enter a check mark in the appropriate box.Enter the month, day, and year of the VPFL claimant222s date of birth.Enter the six digit voluntary plan number.Enter the voluntary plan employer's name.Enter the claimant222s phone number.Enter an 223X224 in the appropriate box for family care or child bonding. If the VP previously paid benefits on a disability pregnancyclaim, and the claimant is now requesting child-bonding benefits for the same child, check the 223Yes224 box. If unsure of the type ofclaim previously paid, mark the 223Unknown224 box.Enter the name of the care recipient (family member) who will receive family care or the name of the child with whom theclaimant will bond.Enter the birth date of the care recipient (family member) or the child with whom the claimant will bond.Enter the date that the foster or adopted child was placed in the claimant222s home.Enter an 223X224 in the appropriate box. If 223Yes224 is checked, enter the employer or plan administrator name and address in the boxbelow. The Department will mail the award information to the address provided.Enter the printed name of the person completing Section A.Enter the phone number of the person completing Section A.Enter the current date. Section B: Information regarding benefits. On retained copy of completed Section A, complete Items 18 226 28 and return within 35 days after final payment for each period of Voluntary Plan Family Leave (California Code of Regulations, title 22, section 3267-1). 18.Enter the Voluntary Plan weekly benefit amount.19.Enter the first date for which benefits were paid.20.Enter the last date for which benefits were paid.21.Enter the number of days for which benefits were paid.22.Enter 223yes224 if the claimant was paid less than his/her full daily benefit rate for one or more days. Enter 223no224 if the claimant did notreceive less than his/her full daily benefit rate for any days which benefits were paid.23.Enter the total dollar amount of benefits paid.24.Enter the amount of PFL benefits that were diverted to satisfy a support obligation. (Enter the amount of benefits withheld underthe Support Intercept Program.) This amount must be included in the total of item 23.25.Enter an 223X224 in the boxes that apply to the current claim status.Benefits Exhausted: The total maximum benefit amount was paid on the claim.PFL claimant has returned to work: Self-explanatory American LegalNet, Inc. www.FormsWorkFlow.com DE 2523F Rev. (12-18) (INTRNET) Page 3 of 3 Benefits Denied: No benefits have been paid. Include with this form a copy of the claimant222s denial letter. You are required to notify the claimant in writing if you deny benefits in whole or in part. A copy of that letter must be sent to the Department with the DE 2523F. Re-established claim: This applies if there has been a break in benefit payment periods for the same or different care recipient or child-bonding claim within the past 12 months. Adjustment: Use if a previous report was submitted, and this is a correction or change to that report. Enter the printed name of the person completing Section B.Enter the phone number of the person completing Section B.Enter the current date. MAIL COMPLETED FORM TO: EDD-Paid Family Leave (PFL) PO Box 997017 Sacramento, CA 95899-7017 American LegalNet, Inc. www.FormsWorkFlow.com