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DI / DE 2517-03
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SAMPLE
, this page for reference only.
DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO
CA
99999-9999
(000) 000-0000
FIRSTNAME M LASTNAME
1234 ANY ST
ANY CITY CA 99999-9999
NOTICE OF DETERMINATION
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
Your claim for Disability Insurance (DI) has been denied from MM/DD/YY through MM/DD/YY because:
The medical certificate does not show that you were examined by or under the care of a physician or practitioner during the period for which you are claiming benefits. (Basis: California Unemployment Insurance Code (CUIC), Section
2708
.)
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 written 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 and be addressed to the office shown above.
State of California / Employment Development Department (EDD)
DE 2517-03 Rev. 4 (03-18)
(INTRANET)
Email Address:
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