DI / DE 2587F

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NOTICE OF AUTOMATIC PAYMENT--PFL

YOUR PAYMENTS

Your claim for Paid Family Leave (PFL) benefits is in an automatic payment cycle. You will not need to return certification forms for payment. Benefit payments will be issued to you approximately every 14 days. If you do not receive a payment within 21 days of your last payment issued to you, please contact this office.

YOUR RESPONSIBILITY

In order to prevent an overpayment of benefits on your claim, you must immediately notify the Department if the care recipient for whom you are providing family care no longer requires your care, you return to work, or you receive wages from your employer. Contact the PFL office by phone and complete and return this form to us immediately. Failure to notify the Department of a change in your claim status can result in penalties including fines, imprisonment, and loss of benefit rights as outlined in the California Unemployment Insurance Code (CUIC).

NOTICE OF CHANGE IN CLAIMANT STATUS

I certify that I returned to work on
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Date
I certify that my family member's (care recipient's) care needs have increased / decreased (circle one) as of
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Date
I certify that my family member (care recipient) is deceased
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(Deceased as of this date)
I certify that my family member (care recipient) no longer needs care as of
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Date
I certify that I received wages while providing family care from
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Date
to
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Date
I certify that another family member began providing family care on
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Date
I certify that I stopped providing family care on
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Date
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Your Signature
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Date

DE 2587F Rev. 3 (7-21) (INTRANET)