DI / DE 2514-49

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
SAMPLE CLIENT
‎1234 ANY STREET
ANY CITY CA 99999-9999
 

Notice of Denied Paid Family Leave (PFL) Benefits - No Registered Domestic Partner Relationship

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:

Our records indicate the person for whom you are providing family care is not your registered domestic partner.

Basis:
California Code of Regulations (CCR), title 22, section 3302-1.

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 mailing address provided above.

Notice of Determination

DE 2514-49 Rev. 4 (12-20) (INTRANET)