DI / DE 2517-40

SAMPLE, this page for reference only

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Notice of Disability Insurance (DI) Determination Failure to Respond to Request for Identity Information

Maling Date:
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Claim Effective Date:
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We are unable to pay you Disability Insurance (DI) benefits from MM/DD/YYYY through when eligible because:

You have not provided the Employment Development Department (EDD) with the requested information to establish your identity, address, Social Security number ownership, and/or verify your wages.

Basis: California Code of Regulations (CCR), Title 22, section ‎2706-8.

This determination is final unless you send a written appeal within 30 days from the mailing of this notification. You may appeal by either:
  • Completing the enclosed Appeal Form (DE 1000A).
  • Writing a detailed statement of why you believe the determination is in error.

Make sure to include your Social Security number on your appeal and send it to the EDD office shown above.

State of California / Employment Development Department (EDD)

DE 2517-40 (2-22) (INTRANET)