DI / DE 2514-62

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 (PFL) Benefits – Death of Care Recipient

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:

Benefits cannot be paid after the date of death of the care recipient.

Basis : California Unemployment Insurance Code (CUIC), section 2679.

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.

DE 2514-62 Rev. 3 (11-18) (INTRANET)