DI / DE 2514-55

SAMPLE, this page for reference only

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

Notice of Denied Paid Family Leave (PFL) Benefits ‑ Care Recipient's Condition Not Serious

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:

The care recipient's illness or injury does not qualify as a "serious health condition" under the law.

Basis:
California Code of Regulations (CCR), title 22, section 3302-2.

If the care recipient's condition changes to a point where it qualifies as a serious health condition and your care is required, you may again submit a claim for Paid Family Leave (PFL) benefits.

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 2514-55 Rev. 3 (03-18) (INTRANET)