DI / DE 2514-41

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX ###
ANY CITY CA 99999-9999
SAMPLE CLIENT
‎1234 ANY ST
ANY CITY CA 99999-9999
 

Notice of Denied Paid Family Leave (PFL) Benefits ‑ False Statement Penalty

Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
We are unable to pay you Paid Family Leave (PFL) benefits beginning MM/DD/YY and ending when ### days have been served because:
You willfully made a false statement or knowingly failed to disclose a material fact in order to obtain Paid Family Leave (PFL) or State Disability Insurance (SDI) benefits.
Basis:
California Unemployment Insurance Code (CUIC), section 2675.

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 2514-41 Rev. 2 (03-18) (INTRANET)