DI / DE 2514-66

SAMPLE, this page for reference only.

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

Notice of Denied Paid Family Leave (PFL) Benefits – Declaration is Missing 

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 initial claim did not include a written declaration from the person assigned to act as the authorized representative for your deceased, mentally incompetent, or incapacitated family member (care recipient).

Basis : California Code of Regulations (CCR), Title 22, Section 3302-1(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 2514-66 Rev. 6 (12-18) (INTRANET)