DI / DE 2514-72

SAMPLE, this page for reference only

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

Notice of Paid Family Leave Claim Date Adjustment – Beginning Date Before Covered Active Duty Notification

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 and ending MM/DD/YY because:

Your military assist claim cannot begin prior to the covered active duty notification date. Therefore, the beginning date of your claim has been adjusted.

Basis : California Unemployment Insurance Code (CUIC) Section 3302.2(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 and send it to the EDD office shown above.

DE 2514-72 (12-20) (INTRANET)