REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION
Please carefully read the following:
By completing this form, I am requesting the Office of Assemblymember Gipson (the “Assemblymember”) to assist me in working with the Employment Development Department (EDD) on my claim. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize EDD and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved.
I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblymember’s office needs additional information, such as my EDD number, the office will contact me to request that information.