Notice of Right to Continue Paid Family Leave (PFL) Benefits Pending Appeal

(Basis: California Code of Regulations (CCR), title 22, section ‎2706-7)

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To appeal the attached Notice of Determination, complete this form and the Appeal Form ‎(DE 1000A); or you may submit your own letter of appeal with this form.

If you file a timely appeal to the Notice of Determination, choose one of the options below by checking the appropriate box:

I request that the PFL program pay me benefits pending the decision on my appeal. I understand that if I do not win my appeal, I may be required to repay these benefits unless it would be against equity and good conscience to require payment. In addition, I understand that if I lose this appeal with the Department but decide to pursue it further with the Appeals Board, the PFL program will not continue to pay me during that process.

or

I request that the PFL program withhold my benefits pending the decision on my appeal. I understand that if I win my appeal, I will receive benefits for the time period to which I previously certified on my PFL claim form as long as I meet all other eligibility requirements.

Please remember to sign and date this form prior to returning it. Attach the appeal form or your appeal letter. Mail both forms to the office address shown below.

Provide only the last 4 digits of your Social Security Number:

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Your Signature:

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Date:

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Paid Family Leave Office PO Box 997017 Sacramento, CA 95899-7017

Phone:1-877-238-4373

DE 6315DF Rev. 3 (7-21) (INTRANET)

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DI / DE 6315DF

Notice of Right to Continue Paid Family Leave (PFL) Benefits Pending Appeal