DI / DE 2514-61

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 – Working

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 MM/DD/YY because:

Our records indicate you did not take time off work during this period to provide family care.

Basis : California Unemployment Insurance Code (CUIC), Sections 3301(a)(1) and 3303.

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 (DE 1000) 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 Employment Development Department (EDD) mailing address provided above.

DE 2514-61 Rev. 7 (12-20) (INTRANET)