DI / DE 2514-11

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 Paid Family Leave (PFL) Claim Date Adjustment - Late Filing

Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

We are unable to pay you Paid Family Leave (PFL) benefits from MM/DD/YY through MM/DD/YY, and we have adjusted the effective date of your claim because:

Your claim was not filed within 41 days of the first compensable day of your family leave

Basis:
California Unemployment Insurance Code (CUIC), section 3301(e).

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 2514-11 Rev. 2 (03-18) (INTRANET)