Who needs a Form DE 2501F?
The form will be useful for participants of the California Paid Family Leave Program (PFL) which grants workers a paid leave (insurance providing income replacement to eligible workers) to care for a sick relative or to take a bond with a new child.
What is Form DE 2501F for?
By submitting this form, a submitter certifies that they are claiming PFL benefits and that throughout the period covered by this claim they were providing care for or bonding with the care recipient named on this form.
All information provided is used by the PFL administration to evaluate applicant's compliance with the rules and terms of the program.
How do I fill out Form DE 2501F?
The following blocks of the form must be filled out to complete the form correctly:
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Applicant’s, employer’s, and person’s whom the applicant is caring for general information;
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Bonding Certification information (to be completed by person claiming benefits to bond with a child);
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Statement of Care Recipient;
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Confirmation of Medical Disclosure Authorization (not to be completed for bonding with child cases);
Once completed and signed, this form must be directed to the Employer’s Development Department office.
