DI / DE 2500E

SAMPLE, this page for reference only

ELECTRONIC BENEFIT PAYMENT (EBP) NOTIFICATION

Name: First Name Middle Name Last Name
XXXXXX
Date Issued: MM/DD/YY
 
Date Issued: MM/DD/YY
Claim Effective Date: MM/DD/YY
Keep this notification for your records.
Name: First Name Middle Name Last Name
 
Weekly Rate: ‎$0000.00
Weekly Rate is for 7-days
This is your notification of authorized Benefit Payment(s) for the period listed below. You will be paid for every day you are eligible for benefits, including weekends.
If you are not paid for any days, you will be notified which days were not paid and why they were not paid in the message area below. The office processing your claim is:
EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 000000 ANY CITY CA 99999-9999
‎(000) 000-0000
Your Benefit Payment covers the following period(s): MM/DD/YY through MM/DD/YY.
Message-Area
Important Notice: If you do not understand any form sent to you by this office, contact us for assistance at the telephone number shown above.

DE 2500E Rev. 7(5-24) (INTRANET)

SAMPLE, this page for reference only

ELECTRONIC BENEFIT PAYMENT (EBP) NOTIFICATION

IMPORTANT MESSAGE: By accepting Employment Development Department (EDD) benefit payments, you are certifying that the following is true for the entire period covered by this EBP notification:
  1. You are the person whose name appears on this notification.
  2. You have reported any money or salary that you have received or that you expect to receive from your employer, and/or any payment received from a Workers’ Compensation program.
  3. Disability Insurance (DI) claim only: You were unable to work due to a disability. Note: Your family member (parent, child, son-in-law, daughter-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner) may be eligible to receive Paid Family Leave (PFL) benefits for providing you care during your disability period, when certified by a physician/practitioner. If you have a pregnancy-related claim, you may be eligible for PFL benefits for bonding. For more information, visit EDD Disability (edd.ca.gov/disability) or call ‎1-877-238-4373. PFL claim only: You (a) provided care for your child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner, or (b) participated in a qualifying event as a result of a family member’s (spouse, registered domestic partner, parent, or child) military deployment to a foreign country, or (c) bonded with a new child. Note: Both parents (biological, registered domestic partners, foster, or adoption) may be eligible for PFL benefits for bonding. For more information, visit EDD Disability edd.ca.gov/disability or call ‎1-877-238-4373.

DE 2500E Rev. 7(5-24) (INTRANET)