DI / DE 2517-24

SAMPLE, this page for reference only.

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

Notice of Benefit Amount Determination

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
SECTION 2656 OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC) PERMITS PAYMENT OF WEEKLY BENEFITS IF YOU ARE RECEIVING LESS THAN YOUR FULL WAGES WHILE YOU ARE DISABLED. BENEFIT PAYMENTS AND WAGES ADDED TOGETHER CANNOT EXCEED YOUR REGULAR WEEKLY WAGE, EXCLUDING OVERTIME PAY, IMMEDIATELY PRIOR TO YOUR DISABILITY.
YOUR BENEFIT PAYMENT, ADDED TO THE WAGES CONTINUED BY YOUR EMPLOYER, EQUALS YOUR REGULAR EARNINGS. AS LONG AS YOU CONTINUE TO RECEIVE SUCH PAYMENT FROM YOUR EMPLOYER, YOUR DISABILITY BENEFITS MAY BE REDUCED.
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 2517-24 Rev. 4 (03-18) (INTRANET)