DI / DE 2517-52

SAMPLE, this page for reference only

DISABILITY INSURANCE
PO BOX 120831
SAN DIEGO CA 92112-0831
SAMPLE CLIENT
‎1234 ANY STREET
ANY CITY 
 

NOTICE OF ALCOHOLIC RECOVERY HOME PROGRAM BENEFIT DETERMINATION

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOU HAVE BEEN PAID ALL OF THE DISABILITY BENEFITS THAT YOU ARE ENTITLED TO BECAUSE:
SECTION 2626.1 OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC) PROVIDES THAT A RESIDENT IN AN ALCOHOLIC RECOVERY HOME IS ELIGIBLE FOR AN ADDITIONAL PERIOD OF SIXTY (60) DAYS DISABILITY BENEFITS FOR CONTINUING RESIDENT SERVICES, PROVIDING A PHYSICIAN/PRACTITIONER CERTIFIES TO THE NEED. THE MAXIMUM BENEFITS PAYABLE FOR RESIDENT STATUS SHALL NOT EXCEED NINETY (90) DAYS IN ANY DISABILITY BENEFIT PERIOD. YOU HAVE EXHAUSTED YOUR MAXIMUM AMOUNT FOR THIS DISABILITY BENEFIT PERIOD.
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 2517-52 Rev. 4 (03-18) (INTRANET)