Instructions For San Francisco Paid Parental Leave Form

Instructions for San Francisco Paid Parental Leave Form

If you are eligible for California Paid Family Leave benefits for new child bonding and you work in San

Francisco, you may also be eligible for “Supplemental Compensation” from your employer. You must

complete the Paid Parental Leave Form to receive Supplemental Compensation for new child bonding

from your employer.

If you have only one employer, complete Sections 1, 2, and 3, and submit the form to your employer

If you have more than one employer, you must provide a completed form to each employer. For each

employer, complete Sections 1, 2, 3, and 4, sign in both Section 3 and Section 4.

Section 1 Instructions:

Fill out your name and address in the first line and the name of the employer in the second line.

Section 2 Instructions:

Your employer needs to know the amount of your weekly California Paid Family Leave benefits for

bonding with a new child. The best way to provide your employer with this information is to check both

boxes, meaning:

1. You are submitting a copy of your “Notice of Computation” to your employer. You should

receive the Notice of Computation (DE429D) in the mail shortly after submitting your EDD

Claim Form. and also

2. When you applied for California Paid Family Leave, you checked the box on the form granting

EDD permission to disclose to your benefit amount to your employer.

Note: your employer may also require you to submit your EDD “Notice of Payment,” which EDD will

send you when the first payment is made.

Section 3 Instructions:

Read the reimbursement agreement, fill in your name in the blank, then sign your name and enter the date

in the Employee Signature blank. You should also have your supervisor or HR representative sign and

date the agreement in the Employer Signature blank.

If you have only one employer, then the form is complete.

If you have more than one employer, complete Section 4.

Section 4 Instructions: If you have more than one employer, the San Francisco law requires you to

provide “information pertaining to wages received from all employers” to each of your employers. In

filling out this section, fill in wages from all employers, including the employer to whom you are

submitting the form. Do not include income earned as an independent contractor.

There are two options for gathering information and completing Section 4 of the form.

Option A. Ask each of your employers for your Normal Gross Weekly Wages over the past three months

or twelve weeks and enter the number in the column for each employer. If you have more than three

employers, attach an additional page with information from other employers as needed. If you receive tips

at any of these jobs, ask your employer for the average all reported tips in the designated column. Please

see the example below.

[DEC 2016 REV]

Instructions For San Francisco Paid Parental Leave Form - 2016