DI / DE 2514-21

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave (PFL) Benefits - Medical Certificate for Care Recipient Not Submitted Within 20 Days

Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

We are unable to pay your claim for Paid Family Leave (PFL) Benefits for the period MM/DD/YY through MM/DD/YY because:

The continued medical certification for your care recipient was not submitted within the 20-day time limit

Basis:
California Code of Regulations (CCR), title 22, section 2706-6(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 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 2514-21 Rev. 3 (03-18) (INTRANET)