DI / DE 2514-57

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX ######
ANY CITY CA 99999-9999
SAMPLE CLIENT
‎1234 ANY STREET
ANY CITY CA 99999-9999
 

Notice of Denied Paid Family Leave Benefits ‑ Eligible for Permanent Disability Benefit Supplement

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 MM/DD/YY because:

You must elect to receive permanent disability (PD) benefits as a supplement to your maintenance allowance benefits under your employer’s workers’ compensation plan. You are eligible to receive PFL benefits only if your combined maintenance allowance and permanent disability (PD) weekly benefit is less than your PFL weekly benefit amount (WBA).

Basis:
California Unemployment Insurance Code (CUIC), sections 2629(d) and 3303.1(a)(2).

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 EDD office shown above.

Notice of Determination

DE 2514-57 Rev. 3 (03-18) (INTRANET)