DI / DE 2517-57

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO CA 99999-9999
FIRSTNAME LASTNAME
‎1234 ANY ST
ANY CITY CA 99999-9999
 

NOTICE OF DETERMINATION

MAILING DATE:
MM/DD/YY
CLAIM EFFECTIVE DATE:
MM/DD/YY
YOUR STATE DISABILITY WEEKLY BENEFIT RATE HAS BEEN REDUCED BECAUSE OUR RECORDS INDICATE YOU ARE ALSO ENTITLED TO RECEIVE PARTIAL DISABILITY BENEFITS FROM ONE OR MORE OF YOUR EMPLOYER'S VOLUNTARY PLANS FOR THE SAME PERIOD. SECTION 3253-1, TITLE 22, 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 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 2517-57 Rev. 3 (03-18)