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DI / DE 2517-13
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SAMPLE
, this page for reference only.
DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO
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
YOUR CLAIM FOR DISABILITY INSURANCE (DI) HAS BEEN DISALLOWED FROM MM/DD/YY THROUGH MM/DD/YY BECAUSE:
THE MEDICAL CERTIFICATE DOES NOT ESTABLISH THAT YOU WERE UNABLE TO PERFORM YOUR REGULAR OR CUSTOMARY WORK DUE TO A DISABILITY. SECTION
2708
OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC).
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 2517-13 Rev. 3 (03-18)
(INTRANET)
Email Address:
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