DI / DE 2517-33

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO CA 99999-9999
FIRSTNAME M LASTNAME
‎1234 ANY ST
‎ANY CITY CA 99999-9999
 

Notice of Adjustment

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOU RECEIVED BENEFIT PAYMENT(S) FOR THE PERIOD MM/DD/YY THROUGH MM/DD/YY FOR WHICH YOU WERE INELIGIBLE.
YOU WERE PAID BENEFITS FOR A PERIOD DURING WHICH YOU ALSO RECEIVED REGULAR WAGES FROM YOUR EMPLOYER.
BASIS: CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC) 2656.
YOUR BENEFITS PAYMENT(S) HAVE BEEN REDUCED TO ADJUST THE PREVIOUS PAYMENT(S) THAT YOU RECEIVED.
This determination is final unless you file an appeal within thirty (30) days from the mailing of this notification. You may appeal by giving a detailed statement as to why you believe the determination is in error. All communications regarding this Disability Insurance (DI) Claim should include your Social Security Number addressed to the office shown above.
STATE OF CALIFORNIA/EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD)

DE 2517-33 Rev. 4 (03-18) (INTRANET)