DI / DE 2514-63

SAMPLE, this page for reference only.

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
Blank space

Notice of Paid Family Leave (PFL) Benefit Reduction – Care Hours Claimed Exceed Care Need

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

We are reducing your Paid Family Leave (PFL) insurance benefits for the period beginning MM/DD/YY and ending MM/DD/YY because:

The amount of time claimed for providing care exceeds the amount of time your family member’s medical provider has determined care is needed.

The medical provider has determined that your participation is warranted for _______ hours per day.

Basis : California Unemployment Insurance Code (CUIC), section 2708(b).

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 2514-63 Rev. 4 (11-18) (INTRANET)