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DI / DE 2517ER
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SAMPLE
, this page for reference only
Notice of Determination Following Eligibility Review
Blank line
Date of Mailing or Service of Notice
Blank line
Claim Effective Date
Blank Box
1
.
Your claim for Disability Insurance benefits has been accepted as previously determined.
2
.
Your claim for Disability Insurance benefits has been denied for the period beginning
Blank Line
and ending
Blank Line
.
3
.
Blank space
Reason(s) for Determination:
a
.
You were unable to establish your identity as the claimant appearing on your claim form. (Basis: California Unemployment Insurance Code (CUIC), Section
2625
.)
b
.
We have been unable to obtain evidence that you were medically treated by the physician or practitioner shown on your medical certification. (Basis: California Unemployment Insurance Code (CUIC), Section
2708
.
)
c
.
You were not employed by the following base period employer(s):
Blank Line
.
Your benefit award will be recomputed accordingly. (Basis: California Unemployment Insurance Code (CUIC), Section
2655
.
)
d
.
You made a false statement/representation or withheld a material fact in order to receive Disability Insurance benefits. (Basis: California Unemployment Insurance Code (CUIC), Section
2675
.)
e
.
You failed to appear at the eligibility review scheduled for you on
Blank Line
.
(Basis: California Code of Regulations (CCR), Title
22
, Section
2675-1
.
)
f
.
Blank Line
.
(Basis: California Code of Regulations (CCR), title
22
, Section
Blank Line
.
)
Blank space
Evidence and your appeal rights are shown on page
2
of this Notice.
Employment Development Department
P.O. Box
Blank Line
City, CA ZIP code
Phone
Blank Line
DE 2517ER Rev 4. (10-21)
INTRANET
SAMPLE
, this page for reference only
Notice of Determination Following Eligibility Review, continued
Blank line
Date of Mailing or Service of Notice
Blank line
Claim Effective Date
Evidence.
The Employment Development Department (EDD) relied on the following evidence in making this determination:
Blank space
Blank Line
, Hearing Officer
Your Appeal Rights
. You have
30
days from the date of mailing of this Notice to take action. If you fail to take action in
30
days, this determination is final.
If you appeared
at the Eligibility Review, you may appeal this Notice of Determination to an Administrative Law Judge (ALJ) either by completing the enclosed
Disability Insurance Appeal Form
(DE 1000A)
, or by writing a detailed statement of why you believe the determination is in error. All communications regarding this Disability Insurance (DI) claim should include your Social Security number. Mail your appeal to the address shown on page
1
of this Notice.
If you did not appear
at the Eligibility Review, you may:
Appeal this Notice of Determination to an Administrative Law Judge (ALJ) by completing the enclosed
Disability Insurance Appeal Form
(DE 1000A)
, or by writing a detailed statement of why you believe the determination is in error.
Request reconsideration (see enclosed
Right to Request Reconsideration Following Non-Appearance at Eligibility Review
(DE 2549)
for specific instructions).
All communications regarding this Disability Insurance (DI) claim should include your Social Security number. Mail your appeal or request for reconsideration to the address shown on page
1
of this Notice.
DE 2517ER Rev 4. (10-21)
INTRANET
Email Address:
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