Notice of Right to Continue Disability Benefits Pending Appeal

(Basis: California Code of Regulations (CCR), title 22, section 2706.5)

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To appeal the attached Notice of Determination, complete this form and the Appeal Form ‎(DE 1000A); or you may submit your own letter of appeal with this form.

If you file a timely appeal to the Notice of Determination, choose one of the options below by checking the appropriate box:

I request the State Disability Insurance (SDI) program pay me disability benefits pending the decision on my appeal. To receive these benefits, I understand that I must continue to file continued claims. I also understand that if the decision on the appeal is against me, I may be required to repay those benefits, unless it is found I received the overpayment without fault on my part and that it would be against equity and good conscience to require repayment. In addition, if I choose to pursue this adverse decision to the Appeals Board, SDI will not continue to pay me.

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I request the SDI program withhold disability benefits pending the decision on my appeal. understand that I must still continue to file continued claims until I either recover or return to work. I also understand that if I win the appeal, I will be paid only those benefits for any period of eligibility for which I have submitted certification and/or medical extension forms to SDI.

Please remember to sign and date this form prior to returning it. Attach the appeal form or your appeal letter. Mail both forms to the office address shown below.

Provide only the last 4 digits of your Social Security Number:

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Sign Your Name:

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Date:

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Disability Insurance Office
P.O. Box

Telephone:‎ (800) 480-3287

DE 6315D Rev. 6 (7-21) (INTRANET)

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DI / DE 6315D

Notice of Right to Continue Disability Benefits Pending Appeal