DI / DE 2517PB

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Mailing Date:
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Claim Effective Date:
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Claim ID:
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Office No:
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Notice of State Disability Insurance (SDI) Determination

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We are unable to pay you State Disability Insurance (SDI) benefits from MM/DD/YYYY through when eligible because:
The information you have provided to the Employment Development Department (EDD) is insufficient to establish your identity, Social Security number ownership, and/or verify your wages.
Basis:
Employment Development Department (EDD)
Phone
This determination is final unless you send a written appeal within thirty (30) days from the mailing date above. You may appeal by completing the enclosed Appeal Form, DE 1000AA, or separately writing a detailed statement of why you believe the determination is in error. Please include your Social Security number on your appeal and send it to the EDD office shown above.

DE 2517PB (4-21) (INTRANET)

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

APPEAL FORM

DO NOT RETURN THIS FORM UNLESS YOU WANT TO APPEAL THE ENCLOSED NOTICE OF DETERMINATION

As shown on the enclosed notice of determination, you are not eligible for all or part of the period claimed. To appeal this decision to an administrative law judge (ALJ), please explain why you disagree with the decision, and return this form to the address above. You must return this form by the appeal deadline timeframe specified on the enclosed notice of determination. The appeal period may be extended for good cause. If your appeal is late, state the reason you are filling late.
I disagree with the decision contained in the notice dated Blank line The reason(s) I disagree is:
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(Attach an additional sheet if more space is required)
While your appeal is pending, you must complete and return a claim certification for the period(s) that you want to claim benefits. If you are found eligible, you will only be paid benefits for periods for which you file a claim certification and meet all other eligibility requirements.
Can you speak English?
If No, give language and dialect: Blank line Social Security No.: Blank line
Name:
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Telephone No.:
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Mailing Address:
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Street No., Apt. No., or P.O. Box
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City
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State
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ZIP Code
Signature of Appellant or Agent:
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Date:
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Your mailing address, if different than above; or your Agent's address: (if applicable)
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FOR DEPARTMENT USE ONLY
EDD verifies that party needs interpreter

DE 1000AA Rev. 1 (12-16) (INTRANET)