EDD Assistance Request Form

In order to assist you with your EDD matter we ask you to complete the information on this form.. Make sure to include your 10 digit CAN = Customer Account Number. You can find your CAN on the letter EDD sent you (via U.S. Mail) with the instructions needed to register your on-line account. We cannot escalate your matter without this information. If you cannot locate your CAN, you can still submit your request but there will be a delay until a member of our office staff contacts you for alternative confirmation information.

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Your Email

Do you have an EDD Customer Account Number (CAN)?

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)

Disability Insurance Claim Number

Reason given by EDD for interruption of benefit payments

EDD Assistance Request Form

Office Information

Capitol Office

Stockton Office