DI / DE 2517-56

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 DETERMINATION

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOUR CLAIM FOR DISABILITY INSURANCE (DI) HAS BEEN REDUCED.
YOU HAVE RECEIVED OR ARE ENTITLED TO RECEIVE CASH PAYMENTS OF TEMPORARY DISABILITY UNDER A WORKERS’ COMPENSATION OR EMPLOYER’S LIABILITY LAW. SECTION 2629 OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC).
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 2517-56 Rev. 3 (03-18) (INTRANET)