State Disability Form
Download a blank fillable State Disability Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Disability Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4&ODLP IRU 'LVDELOLW\ ,QVXUDQFH %HQHILWV ²
&ODLP 6WDWHPHQW RI (PSOR\HH
TYPE or PRINT with BLACK INK.
1A. YOUR SOCIAL SECURITY NUMBER
1B. IF YOU HAVE EVER USED OTHER SOCIAL SECURITY NUMBERS, SHOW THOSE
2. STATE GOVERNMENT EMPLOYEE
(
,
#.)
NUMBERS BELOW
IF YES
INDICATE BARGAINING UNIT
(
#)
YES
UNIT
NO
4. LAST DATE YOU WORKED
3. DATE YOUR DISABILITY BEGAN
5. HAVE YOU WORKED ANY FULL OR PARTIAL
6. DATE YOU RECOVERED OR
DAYS SINCE YOUR DISABILITY BEGAN?
RETURNED TO WORK (
)
IF ANY
YES
NO
MM
DD
YY
MM
DD
YY
MM
DD
YY
7. GENDER
8. YOUR LEGAL NAME
9. YOUR DATE OF BIRTH
MALE
FEMALE
FIRST NAME
MIDDLE NAME OR INITIAL
LAST NAME
MM
DD
YY
10. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED
11. LANGUAGE YOU PREFER TO USE
________________________
ENGLISH
ESPAÑOL
OTHER
12. YOUR MAILING ADDRESS
(
—
—
“PMB#”
.)
IF YOU WISH TO RECEIVE MAIL AT A PRIVATE MAIL BOX
NOT A US POSTAL SERVICE BOX
YOU MUST SHOW THE NUMBER IN THE
SPACE
/
/
.
.
/
#
# (
#)
NUMBER
STREET
P
O
BOX
APARTMENT OR SPACE
PMB
PRIVATE MAIL BOX
(
)
CITY
STATE
COUNTRY
IF NOT UNITED STATES OF AMERICA
ZIP CODE
13. YOUR AREA CODE
TELEPHONE NUMBER
14. YOUR RESIDENCE ADDRESS,
AND
IF DIFFERENT FROM YOUR MAILING ADDRESS
/
/
#
NUMBER
STREET
APARTMENT OR SPACE
(
)
(
)
CITY
STATE
COUNTRY
IF NOT UNITED STATES OF AMERICA
ZIP CODE
15. WHY DID YOU STOP WORKING?
16. YOUR LAST OR CURRENT EMPLOYER –
-
,
“
”
IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF
EMPLOYMENT
ENTER
SELF
‘
[
:
(
:
)]
EMPLOYER
S AREA CODE AND TELEPHONE NUMBER
NAME OF EMPLOYER
STATE GOVERNMENT EMPLOYEES
PROVIDE THE AGENCY OR DEPARTMENT NAME
FOR EXAMPLE
CALTRANS
(
)
/
/
# (
:
)
NUMBER
STREET
SUITE
STATE GOVERNMENT EMPLOYEES
PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE
(
)
CITY
STATE
COUNTRY
IF NOT UNITED STATES OF AMERICA
ZIP CODE
17. YOUR REGULAR OCCUPATION
18. IF YOUR EMPLOYER CONTINUED
19. MAY WE DISCLOSE BENEFIT PAYMENT
TO PAY YOU, INDICATE TYPE OF PAY
INFORMATION TO YOUR EMPLOYER?
________________
SICK
VACATION
OTHER
YES
NO
20. SECOND EMPLOYER (
)
IF YOU HAVE MORE THAN ONE EMPLOYER
‘
EMPLOYER
S AREA CODE AND TELEPHONE NUMBER
NAME OF EMPLOYER
(
)
/
/
#
NUMBER
STREET
SUITE
(
)
CITY
STATE
COUNTRY
IF NOT UNITED STATES OF AMERICA
ZIP CODE
21. AT ANY TIME DURING YOUR DISABILITY WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT AUTHORITIES BECAUSE YOU WERE CONVICTED OF VIOLATING A LAW
OR ORDINANCE?
“
,”
: ____________________________________________________________________________________
IF
YES
INDICATE NAME OF FACILITY
YES
NO
DE 2501 Rev. 77 (3-06) (INTERNET)
Page 1 of 4
CU
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form De 1964 - Claim For Refund Of Excess California State Disability Insurance Deductions - Ca Employment Development Dept.
Financial
Form De 1378a - Application For Unemployment Insurance, State Disability Insurance, And Paid Family Leave Elective Coverage - 2016
Legal
Related Categories
Parent category: Legal