DI / DE 2532F

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Mailing Date:
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Claimant's Name:
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For Office Use Only:
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Notice of Incomplete Paid Family Leave (PFL) Claim Form Returned to Medical Provider

 
Care Recipient's Name:
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MEDICAL PROVIDER:

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Please return promptly and include this notice so the claim forPFL benefits filed by your patient’s care provider may be processed.

The enclosed "Doctor's Certificate" is being returned to you for the reason(s) checked below:

All communications regarding this PFL claim must include the claimant's Social Security number and be sent to the address shown on the enclosed, pre-addressed, reply envelope.

Paid Family Leave Office
P.O. Box 45011
Fresno, CA 93817-5011
‎877-238-4373
CLAIMANT:
Your claim or continued claim for PFL benefits has been returned to your care recipient's medical provider as indicated above. No determination can be made as to your eligibility for benefits until the claim form is returned to our office.

DE 2532F Rev. 4 (11-21) (INTRANET)