Report Independent to EDD Form
If you would rather print this form, fill it out and fax it over to us, please click here and Fax it to (310) 732-1339
Business Information:
Date: Tax ID:
EDD#: SSN: - -
Business Name: Contact Name:
Address: City: State: Zip Code:
Telephone: Cell: Fax:
Independent Contractor Information:
First Name: Middle Name: Last Name:
SSN: - - Address:
City: State: Zip Code:
Start Date of Contract: Amount of Contract:
Contract Expiration Date: Is the contract ongoing? Yes No
First Name: Middle Name: Last Name:
SSN: - - Address:
City: State: Zip Code:
Start Date of Contract: Amount of Contract:
Contract Expiration Date: Is the contract ongoing? Yes No