DI / DE 817DIS

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Date:
Blank Line
Claim ID:
Blank Line
CED:
Blank Line

Declaration of Forged Endorsement of Disability Insurance Check

 

To report a forged endorsement of a Disability Insurance (DI) benefit check:

  1. Complete, sign, and date all copies of the enclosed Declaration of Forged Endorsement of Disability Insurance (DI) Check, DE 817DIS. Note: Departmental policy requires a separate DE 817DIS packet for each check reported missing, lost, or stolen. Listing multiple checks will delay processing.
  2. Complete, sign, and date PART I of the enclosed Claimant Missing Check Incident Report, DE 8784.
  3. Return the original, duplicate, and triplicate of the DE 817DIS and the DE 8784 to us in the enclosed envelope.

You may keep this transmittal and the claimant copy of the DE 817DIS for your records.

If you have any questions about completion of this Declaration, please call our customer service center at ______________ Blank Line. Hearing and speech-impaired persons only may contact us via teletypewriter (TTY) at ‎1-800-563-2441.

Disability Insurance (DI) Program Representative

Enclosures:
DE 817DIS
DE 8784
Courtesy Reply Envelope
 
DE 817DIS Rev. 18 (4-21) (INTRANET)
Instructions - You May Keep This Page For Your Records

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Claim ID:
Blank Line
CED:
Blank Line
Office Number:
Blank Line

Declaration of Forged Endorsement of Disability Insurance Check

 
I,
Blank Line
, residing at
Blank Line
, 
Blank Line
Blank Line
, declare that the endorsement of the
Disability Insurance (DI) check listed below, purporting to be endorsed by
Blank Line
, and
paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;
Check Number Issue Date Number Benefit Days Through Date Amount
___________Blank Space MM/DD/YYYY ___________Blank Space MM/DD/YYYY ___________Blank Space
I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed on
Blank line 
MONTHDAYYEAR
at
Blank line 
CITY STATE
Blank line 
PAYEE'S SIGNATURE
Blank line 
DISABILITY INSURANCE REPRESENTATIVE
Return original, duplicate, and triplicate. Keep the transmittal/instructions and the claimant copy for your records.
DO NOT WRITE IN SPACE BELOW
Paid by State Treasurer on
Blank Line
Contents examined and reissuance recommended by Insurance Accounting Division
By
Blank Line
Date
Blank Line
Reissuance approved by Investigation Division
By
Blank Line
Date
Blank Line
DE 817DIS Rev. 18 (4-21) (INTRANET)
Original

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Claim ID:
Blank Line
CED:
Blank Line
Office Number:
Blank Line

Declaration of Forged Endorsement of Disability Insurance Check

 
I,
Blank Line
, residing at
Blank Line
, 
Blank Line
Blank Line
, declare that the endorsement of the
Disability Insurance (DI) check listed below, purporting to be endorsed by
Blank Line
, and
paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;
Check Number Issue Date Number Benefit Days Through Date Amount
___________Blank Space MM/DD/YYYY ___________Blank Space MM/DD/YYYY ___________Blank Space
I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed on
Blank line 
MONTHDAYYEAR
at
Blank line 
CITY STATE
Blank line 
PAYEE'S SIGNATURE
Blank line 
DISABILITY INSURANCE REPRESENTATIVE
Return original, duplicate, and triplicate. Keep the transmittal/instructions and the claimant copy for your records.
DO NOT WRITE IN SPACE BELOW
Paid by State Treasurer on
Blank Line
Contents examined and reissuance recommended by Insurance Accounting Division
By
Blank Line
Date
Blank Line
Reissuance approved by Investigation Division
By
Blank Line
Date
Blank Line
DE 817DIS Rev. 18 (4-21) (INTRANET)
Duplicate

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Claim ID:
Blank Line
CED:
Blank Line
Office Number:
Blank Line

Declaration of Forged Endorsement of Disability Insurance Check

 
I,
Blank Line
, residing at
Blank Line
, 
Blank Line
Blank Line
, declare that the endorsement of the
Disability Insurance (DI) check listed below, purporting to be endorsed by
Blank Line
, and
paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;
Check Number Issue Date Number Benefit Days Through Date Amount
___________Blank Space MM/DD/YYYY ___________Blank Space MM/DD/YYYY ___________Blank Space
I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed on
Blank line 
MONTHDAYYEAR
at
Blank line 
CITY STATE
Blank line 
PAYEE'S SIGNATURE
Blank line 
DISABILITY INSURANCE REPRESENTATIVE
Return original, duplicate, and triplicate. Keep the transmittal/instructions and the claimant copy for your records.
DO NOT WRITE IN SPACE BELOW
Paid by State Treasurer on
Blank Line
Contents examined and reissuance recommended by Insurance Accounting Division
By
Blank Line
Date
Blank Line
Reissuance approved by Investigation Division
By
Blank Line
Date
Blank Line
DE 817DIS Rev. 18 (4-21) (INTRANET)
Triplicate

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Claim ID:
Blank Line
CED:
Blank Line
Office Number:
Blank Line

Declaration of Forged Endorsement of Disability Insurance Check

 
I,
Blank Line
, residing at
Blank Line
, 
Blank Line
Blank Line
, declare that the endorsement of the
Disability Insurance (DI) check listed below, purporting to be endorsed by
Blank Line
, and
paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;
Check Number Issue Date Number Benefit Days Through Date Amount
___________Blank Space MM/DD/YYYY ___________Blank Space MM/DD/YYYY ___________Blank Space
I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed on
Blank line 
MONTHDAYYEAR
at
Blank line 
CITY STATE
Blank line 
PAYEE'S SIGNATURE
Blank line 
DISABILITY INSURANCE REPRESENTATIVE
Return original, duplicate, and triplicate. Keep the transmittal/instructions and the claimant copy for your records.
DO NOT WRITE IN SPACE BELOW
Paid by State Treasurer on
Blank Line
Contents examined and reissuance recommended by Insurance Accounting Division
By
Blank Line
Date
Blank Line
Reissuance approved by Investigation Division
By
Blank Line
Date
Blank Line
DE 817DIS Rev. 18 (4-21) (INTRANET)
Claimant Copy

DIMFA SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

 

Claimant Missing Check Incident Report

Check Number
 
Week Ending
(UI) (DI) 
Blank Line
 
Blank Line
(UI) (DI) 
Blank Line
 
Blank Line
(UI) (DI) 
Blank Line
 
Blank Line
PART I - to be completed by Claimant at the time he/she executes the Declaration of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F). PLEASE PRINT CLEARLY.
1. NameBlank space 2. Claim IDBlank space
3. Driver License/Identification Card NumberBlank space 4. Full Date of BirthBlank space
5. Current AddressBlank space 6. Phone NumberBlank space
7. Names of Other People Using This Same AddressBlank space 8. Is Address Above Same as Address of Checks?
9. If address above is different than address of check, did you file a change of address with the Post Office?
If yes, approximate date:
Blank line  
10. Please check the box next to the true answer below and sign your name at the end of each line.
Did you receive this check? Blank line 
Did you lose this check after receiving it? Blank line 
Did you endorse this check after receiving it? Blank line 
Did you authorize anyone to sign or cash this check? Blank line 
11. Complete for Lost or Stolen Checks:
If check was stolen, did you report it?
If yes, to whom?
Blank line  
 
Blank line  
 
Date Reported:
Blank line  
Additional comments (circumstances pertaining to the missing check)
Blank line 
Blank line 
Claimant Signature Blank space Date Blank space
PART II - to be completed by Departmental Representative after claimant has examined front and back of copy of missing check(s) and has executed Declaration(s) of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F)
1. Can claimant identify individual who signed his/her name as first endorsement?
If yes, answer below:
Name Blank line  Relationship Blank line 
Address Blank line  Phone Number Blank line 
2. Can claimant identify individual or entity who cashed this check (second endorser)?
If yes, answer below:
Name/Business Blank line  Relationship Blank line 
Address Blank line  Phone Number Blank line 
EDD RepresentativeBlank space Telephone #Blank space Office #Blank space DateBlank space
DE 8784DIS (9-21) (INTRANET)