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DI / DE 2517-23
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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 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.
You are not eligible for daily benefits from MM/DD/YY through MM/DD/YY because sick leave pay issued yearly by your employer has been allocated to this 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 2517-23 Rev. 3 (03-18)
(INTRANET)
Email Address:
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