DI / DE 2514-47

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
Blank Box

Notice of Denied Paid Family Leave Benefits - Military Documentation Not Provided

Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

We are unable to pay you Paid Family Leave (PFL) benefits for MM/DD/YY through when eligible because:

You did not provide military documentation to support that the military member is on covered active duty, impending call, or order to covered active duty status.
Basis:
(CUIC Section 3307)
You may become eligible for PFL benefits if you send us a copy of one of the following:
  • Covered active duty orders.
  • Letter of impending call or order to covered duty.
  • Documentation of military leave signed by the approving authority for military member’s rest and recuperation.

This determination is final unless you send a written appeal within thirty days from the mailing date above. You may appeal by completing the enclosed Appeal Form or separately writing a detailed statement of why you believe the determination is in error. Please include your Social Security number on your appeal and send it to the Employment Development Department office shown above.

DE 2514-47 (12-20) (INTRANET)