DI / DE 2514-03

SAMPLE, this page for reference only

EDD - PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
SAMPLE CLIENT
‎1234 ANY STREET
ANY CITY CA 99999-9999

Notice of Denied Paid Family Leave Benefits - Self Employed, No Elective Coverage

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:

You were self-employed and not covered for benefits under the Disability Insurance Elective Coverage (DIEC) Program at the time you stopped working to provide family care.

Basis:
California Unemployment Insurance Code (CUIC), sections
140.5
,
708
, and
708.5

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 2514-03 Rev. 3 (12-20) (INTRANET)