DI / DE 2517-53

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 DRUG-FREE RESIDENTIAL FACILITY 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 RECEIVE.

SECTION 2626.2 OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC) PROVIDES THAT A RESIDENT IN A DRUG-FREE RESIDENTIAL FACILITY IS ELIGIBLE FOR A PERIOD NOT IN EXCESS OF FORTY-FIVE (45) DAYS OF DISABILITY BENEFITS WHILE RECEIVING RESIDENT SERVICES. HOWEVER, IF YOU WERE STILL A RESIDENT ON THE DAY FOLLOWING THE LAST DAY COVERED BY YOUR BENEFIT PAYMENT AND A PHYSICIAN/PRACTITIONER WILL CERTIFY TO YOUR NEED FOR CONTINUING RESIDENT SERVICES, IMMEDIATELY CONTACT THIS OFFICE. YOU MAY BE ELIGIBLE FOR ADDITIONAL BENEFITS FOR A PERIOD NOT IN EXCESS OF FORTY-FIVE (45) DAYS.

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 2517-53 Rev. 5 (03-18) (INTRANET)