DI / DE 8517-50

SAMPLE, this page for reference only

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 0000
STOCKTON 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

The recent Non-Industrial Disability Insurance (NDI) claim form received from you has been determined to be a continuation of your disability benefit claim period which began MM/DD/YY. The maximum benefit amount (MBA) of your claim period was 182 days. There is (are) 182 day(s) remaining.

REASON FOR DETERMINATION:

Article 
10
, Section
10.5a
-
MOU
 for October 
18, 1988
- June
30, 1991

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 Non-Industrial Disability Insurance (NDI) Claim should include your Social Security Number and be addressed to the office shown above.

State of California/Employment Development Department (EDD)

DE 8517-50 (03/18) (INTRANET)