DI / DE 2514-40

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave (PFL) Benefits - Benefit Rights Forfeiture

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 because:

Your eligibility for benefits is forfeited for a total of 52 weeks from the date a criminal complaint was filed against you because you have been convicted of a wrongful act to obtain or increase benefits under the Unemployment Insurance (UI) Code.

Basis : California Unemployment Insurance Code (CUIC), section 1263(a)

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 2514-40 Rev. 2 (03-18) (INTRANET)