DI / DE 4400F

SAMPLE, this page for reference only

EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD), STATE OF CALIFORNIA

NOTICE OF OVERPAYMENT - PAID FAMILY LEAVE (PFL)

CLAIM DATE: MAIL DATE: AMOUNT OVERPAYMENT: PENALTY AMOUNT: WAIVED AMOUNT: TOTAL AMOUNT DUE:
MM/DD/YY MM/DD/YY  Blank Space  Blank Space  Blank Space  Blank Space
SAMPLE CLIENT
1234 SAMPLE ST
ANY CITY, CA 99999-9999
EDD - PFL
PO BOX 00000000
ANY CITY CA 99999-9999

‎(000) 000-0000

 
Blank Line

Our records indicate that you were overpaid Paid Family Leave (PFL) insurance benefits.

The overpayment is for the period
MM/DD/YY through MM/DD/YY
 
MM/DD/YY through MM/DD/YY
 
MM/DD/YY through MM/DD/YY
 
MM/DD/YY through MM/DD/YY
 
MM/DD/YY through MM/DD/YY
 
MM/DD/YY through MM/DD/YY

EXPLANATION:

"Explanation text."

DE 4400F Rev. 3 (12-18) (INTRANET)

SAMPLE, this page for reference only

You are liable to repay the total amount of this overpayment. If an amount is entered in the "Penalty Amount" box above, then you have been assessed a 30% penalty as a result of your false statement or misrepresentation.

Basis: California Unemployment Insurance Code (CUIC), sections 2735 through 2736.

PAYMENT: Make your check or money order payable to the Employment Development Department (EDD), include your Social Security number, and forward payment along with this notice to: EDD/PFL, PO Box 45012, Fresno, CA, 93718-5012, using the enclosed return envelope. DO NOT FORWARD APPEAL LETTERS OR OTHER CORRESPONDENCE TO THE FRESNO ADDRESS.

The State Controller may deduct any amount you owe to us from money, including tax refunds, which the State owes you (Government Code Section 12419.5).

APPEAL RIGHTS: This determination is final unless you file an appeal within thirty days from the mailing of this notification. You may appeal by giving a detailed statement regarding why you believe this determination was made in error. If you decide to appeal, include your Social Security number in the letter and forward it to: EDD/PFL, PO Box 997017, Sacramento, CA, 95799-7017 . DO NOT FORWARD PERSONAL CHECKS OR MONEY ORDERS TO THE SACRAMENTO ADDRESS.

You may contact us by phone at the number listed above if you have any questions regarding this notification.

DE 4400F Rev. 3 (12-18) (INTRANET)