DI / DE 2514-33

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave (PFL) Benefits ‑ Initial Claim Returned Late

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:

The incomplete claim form that was returned to you was not sent back to the PFL office within 10 days of the mailing date.
Basis:
California Unemployment Insurance Code (CUIC), section 3301(e).

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 2514-33 Rev. 2 (03-18) (INTRANET)