DI / DE 2514-42

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave Benefits - Another Family Member Available to Provide Family Care

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:

For that period, our records indicate another family member was ready, willing, able, and available to provide family care during the same period of time in a day or days that you were providing care.

Basis:
California Code of Regulations (CCR), title 22, section 3303.1(a)-1.

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 2514-42 Rev. 4 (12-20) (INTRANET)