NOTICE OF DETERMINATION - CLAIM INFORMATION SUBMITTED UNTIMELY

MAILING DATE:

MM/DD/YY

CLAIM EFFECTIVE DATE:

MM/DD/YY

Your claim for Disability Insurance (DI) has been disallowed from MM/DD/YYYY through when eligible because:

The missing claim information that you provided was submitted untimely. The Department must receive missing claim information within 10 days of the date of request in order to continue claim processing.

You established good cause for filing your claim late, however, you delayed filing your claim an additional ______ blankline days after the reason for good cause ended.

Basis: California Unemployment Insurance Code (CUIC), section 2706.1.

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.

DE 2517-81 Rev. 2 (4-21) (INTRANET)

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DI / DE 2517-81

NOTICE OF DETERMINATION - CLAIM INFORMATION SUBMITTED UNTIMELY