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Uncashed Benefit Payment Check or Unclaimed Electronic Benefit Payment Claim Form

Due to changes in State law, effective July 1, 2016, claims for uncashed checks (stale-dated warrants) and unclaimed electronic benefit payments do not require the $25 filing fee and should be filed directly with the EDD. For replacement of benefit payments that are:

• More than three years old from date of issue, fill out this claim form.
• Less than three years old from date of issue, contact the Unemployment Insurance (UI) Office at ‎1-800-300-5616 or the Disability Insurance Office at ‎1-800-480-3287.

Instructions for completing this claim form.

Customer Information:

1. Provide the person’s full name.
2. Provide the Social Security number.
3. Provide the complete mailing address.
4. Provide a daytime phone number, including area code.

Attorney or Representative Information:

1. Provide full name of attorney or representative.
2. Provide relationship to claimant information (attorney, power of attorney, legal guardian, conservator, or heir).
3. Provide the complete mailing address.
4. Provide a daytime phone number, including area code.

Claim Information:

1. Identify the type of benefit payment (unemployment, disability, or Paid Family Leave).
2. Indicate whether this claim is for a benefit payment check that was never cashed.
3. Provide the exact name on the check.
4. Provide the dollar amount of the check.
5. If you have the original check, provide a copy of the front and the back of the check.
6. Note if this claim is for an unclaimed electronic benefit payment (debit card that was never activated or direct deposit payment).
7. Have you received a notice from Money Network or Bank of America stating the monies from the issued debit card or direct deposit payment were returned to the EDD?
8. Exact spelling of the name on notice from Money Network or Bank of America.
9. Provide the dollar amount.
10. Describe the issue.
11. Read statement before signing this claim form.
12. The claimant or representative must sign here.
13. Date claim form was signed.

Please be sure your claim form is complete.

DE 903SD Rev. 1 (2-24) (INTRANET)