DI / DE 2514-52

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave (PFL) Benefits ‑ Evidence of Relationship to Child Not Submitted

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:

You did not provide documented evidence of your qualifying relationship to the child with whom you wish to bond.

Basis:
California Code of Regulations (CCR), title  22, section 2708(c)-1.

You may become eligible for Paid Family Leave (PFL) benefits if you send us a copy of one of the following:

  • child's birth certificate
  • child's hospital discharge record
  • Declaration of Paternity, CS-909
  • Foster Care Placement Record, SOC 815
  • Certificate of Placement, AD-907
  • child's passport showing INS Stamp I-551
  • Independent Adoption Placement Agreement, AD-924
  • Other documents listed in California Code of Regulations (CCR), title  22, section 2708(c)-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 office shown above.

Notice of Determination

DE 2514-52 Rev. 3 (03-18) (INTRANET)