PAID LEAVE APPEAL REQUEST FORM
U P D A T E D DEC EMBE R 2020
Paid Leave Appeal Request Form
You may use this form to appeal if you disagree with a decision you received from us. An appeal cannot be filed
until a determination has been made. Please use one request form per decision you wish to appeal.
For instructions on filing an appeal, refer to the decision letter we sent you. You can read more about appeals in the
Paid Family and Medical Leave Benefit Guide at paidleave.wa.gov/benefit-guide
and on our website at
paidleave.wa.gov. When completed, print this page and fax or mail it to the address listed below. Appeals must be
filed within 30 days after the date of notification or mailing, whichever is earlier (RCW 50A.50.010).
Your contact information
Claim ID, Social Security Number, or ITIN:
Name (first and last):
Phone number:
Email address:
Current mailing address:
City:
State:
Zip:
Additional information
Do you need an interpreter?
Yes
No
If yes, please list your preferred language:
Employer name:
UBI# (if known):
Please tell us why you disagree with the decision you are appealing.
I certify under penalty of perjury that all the information included on this form is true and accurate and I understand
that information involving the investigation and determination is to be made available to all interested parties (RCW
50A.40.020).
Signature: Date:
Mail or fax to: Employment Security Department, Paid Family and Medical Leave Care Center, PO Box 19020 •
Olympia, WA 98507-0020 • Fax: 833-525-2273
The Employment Security Department is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals
with disabilities. Language assistance services for limited English proficient individuals are available free of charge. Washington Relay Service: 711
