DI / DE 2514-50

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 - Relationship to Care Recipient

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:

Your relationship to the care recipient does not qualify you for Paid Family Leave (PFL) benefits. To qualify for Paid Family Leave (PFL) benefits, the care recipient must be your child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner.

Basis : California Unemployment Insurance Code (CUIC), Sections 3301(a)(1) and 3303

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 2514-50 Rev. 4 (03-18) (INTRANET)