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DI / DE 2517-02
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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 disallowed from MM/DD/YY through MM/DD/YY because:
You were not continuously disabled and unemployed for at least eight consecutive days. Section
2706-1(a)
of title
22
of the California code of regulations (CCR).
This determination is final unless you file an appeal within thirty
(30)
days from the mailing of this notification. You may appeal by mailing a written, 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 and be addressed to the office shown above.
State of California / Employment Development Department (EDD)
DE 2517-02 Rev. 3 (03-18)
(INTRANET)
Email Address:
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