DI / DE 4365PI

SAMPLE, this page for reference only

DISABILITY INSURANCE (DI)
PO BOX 989733
WEST SACRAMENTO CA 95798-9733
RETURN TO: 
DISABILITY INSURANCE (DI) PO BOX 989733 WEST SACRAMENTO CA 95798-9733
FIRST NAME AND LAST NAME
STREET ADDRESS
CITY, STATE, ZIP CODE
UNITED STATES
Disability Insurance (DI) Phone Numbers:
English:
1-800-480-3287
Spanish:
1-866-658-8846
TTY (non-voice):
1-800-563-2441
Website:
edd.ca.gov/disability
Mail Date:
MM/DD/YYYY

Notice and Request for Eligibility Information

We are gathering information from all Disability Insurance (DI) claimants at this address to help us make a decision regarding your eligibility for DI benefits. You are receiving this notice because the Employment Development Department (EDD) needs to verify your identity and address for one of the following reasons:

  • If you have not yet received any DI benefit payments on this claim, we cannot begin making those payments until you have verified your identity and address.
  • If you have been receiving DI benefits, the EDD has temporarily suspended your benefits until you verify your identity and address because your claim may be tied to fraudulent activity.

The EDD is unable to issue benefit payments, or lift the temporary suspension of your benefits, until you individually complete a copy of this form and provide verification documents so that we can confirm you are eligible for benefits or determine whether your identity has been compromised.

Each DI claimant at this address must complete, sign, and mail this form along with their required supporting documentation, to the address listed above by MM/DD/YYYY

Failure to provide the below information and the supporting documentation, may result in your disqualification from receiving future DI benefits. You may be required to pay back the DI benefits you already received and penalties.

Write your full name, Claim ID, Social Security number (SSN) or EDD Customer Number (ECN), and date of birth below:

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Name
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Claim ID
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SSN or ECN
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Date of Birth
Provide the following information:
  1. Your current mailing address:
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  2. Your current residential address:
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  3. How long have you lived at this address?
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  4. Provide all addresses you have used during the past three years. (Begin with your most recent mailing and/or residential address, include the full street address or PO Box, city, state, and ZIP Code.) If you need more space, you may write on the back of this form.
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    Sign and date the back of this form. Also send copies of the documents requested on the back on this form.

DE 4365PI (2-22) (INTRANET)

SAMPLE, this page for reference only

Provide at least one photocopy of identification showing your full name, picture, and your date of birth (for example, state-issued driver license, state-issued identification card, passport or resident alien registration card).

Provide at least one document as proof of your residence, showing your full name and address by submitting at least one of the following documents:

  • A utility bill (electricity, gas, garbage, or sewer), cable TV, internet, phone, or property tax bill.
  • Insurance, bank, or mortgage statement, or current and signed rental agreement or lease agreement.
  • Proof that you are a renter or authorized user of a PO Box or Private Mail Box.

Sign and date below before mailing this form with the required information to the address listed on the first page.

I understand the law provides penalties if I make false statements or withhold facts to obtain benefits. I declare under penalty of perjury that the information I am providing and the documents I am submitting are true and correct and belong to me.
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Print your name
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Signature
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Date

DE 4365PI (2-22) (INTRANET)