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Preferred Language: English

Section 2 - Employer Information

Employer Name: Tesla Motors Occupation: Materials Planner

State GovernmentEmployee?

No If Yes, indicateBargaining Unit Number:

May we disclose benefitpayment information toyour employer(s)?

Yes Do you have more thanone employer?

No

Reason for ReducingWork Hours or StoppingWork:

Bonding with a child If Other, pleasespecify:

Employer MailingAddress:

45500 Fremont BlvdFremont, CA 94538-6326United States

Employer PhoneNumber:

Section 3 - Bonding Certification

Relationship to Child: Biological Child If you select FosterCare, Adoption or

Guardianship, pleaseprovide the date ofplacement:

Section 4 - Childs Legal Name and Information

Childs Social SecurityNumber (if available):

Childs Legal Name: Lucas Moss

Childs Gender: Male Child's Date of Birth: 10-23-2014

View Claim for Paid Family Leave (PFL) Benefits Parts A & B -- Statement of Claimant & BondingCertification (DE 2501F)Receipt Number: R100000022248518

Section 1 - Personal Information

Social Security Number: XXX-XX-8375 EDD Customer AccountNumber:

3115114787

Legal Name: MITCHELL MOSS Other Names (If any,under which you haveworked):

Date of Birth: 08-29-1985 Gender: Male

Mailing Address: 3314 San Marino AveSan Jose, CA 95127-1137United States

Phone Number: 831-419-4965

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Is the childs residence address different fromyour residence address?

No

Section 5 - Proof of Relationship

Please indicate the type of Proof ofRelationship you plan to provide from the list ofapproved Proof of Relationship documents:

Child's Hospital Birth Certificate

Section 6 - Childs Residence Address

Do not include PO Box, PMB, General Delivery or Rural Route Number.

Childs Residence

Address:

577 Wyoma Pl

Milpitas, CA 95035-3608United States

Section 7 - Additional Questions

Date You Last Worked: 10-22-2014

If the date you want your Paid Family Leave Claim to begin is prior to the Childs Birth Date (or the dateof foster care or adoption placement), you will be disqualified for the time period prior to Childs Birth Date(or the date of foster care or adoption placement).

Date You Want YourPaid Family Leave Claim

to Begin:

10-23-2014 Will you work at any timeduring your family leave?

No

Your claim effective datebegins your non-payablewaiting period. Wouldyou like to be paid sixcontinual weeks ofbenefits after your non-payable waiting periodhas been served?

Yes If No, Date You Wantto be Paid Through:

Date You Returned toWork:

Date You Plan to Returnto Work:

12-11-2014

If your employer(s)continued or will continueto pay you during yourfamily leave, indicatetype of pay:

Sick, EmployerRequired Vacation

If Other, pleasespecify:

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At any time during yourPaid Family Leave, wereyou in the custody of lawenforcement authoritiesbecause you wereconvicted of violating alaw or ordinance?

No Have you claimed or doyou plan to claimWorkers' Compensationbenefits for any portionof the period covered bythis claim?

No

Section 8 - Declaration

By my signature on this bonding certification, I authorize the medical provider, adoption agency, adoptionparty(ies), or foster care placement agency to disclose to the Employment Development Department allfacts concerning the birth, adoption, or foster care placement of the above-named child. I understand thatwillfully making a false statement or concealing a material fact in order to obtain payment of benefits is aviolation of California law punishable by imprisonment or fine or both. I declare under penalty of perjury

that the foregoing statement, including any accompanying statements or documents, is to the best of myknowledge and belief true, correct, and complete. I agree that photocopies of this authorization shall beas valid as the original, and I understand that authorizations contained in this claim statement are grantedfor a period of fifteen years from the date of my signature or the effective date of the claim, whichever islater.

By my signature on this claim statement, I (1) claim Paid Family Leave benefits and certify thatthroughout the period covered by this claim I was providing care for or bonding with the care recipientnamed above; (2) authorize my employer(s) to disclose to EDD all facts concerning my employment thatare within their knowledge; and (3) authorize release and use of information as stated in the InformationCollection and Access section of the Important Paid Family Leave Program Information page. Iunderstand that willfully making a false statement or concealing a material fact in order to obtain paymentof benefits is a violation of California law punishable by imprisonment or fine or both. I declare underpenalty of perjury that the foregoing statement, including any accompanying statements, is to the best of

my knowledge and belief true, correct, and complete. I agree that photocopies of this authorization shallbe as valid as the original, and I understand that authorizations contained in this claim statement aregranted for a period of fifteen years from the date of my signature or the effective date of the claim,whichever is later.

Submitted by: MITCHELL MOSS Submitted on: 10-27-2014 04:24 PM

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