DI / DE 2517-55

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 DETERMINATION

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOUR DISABILITY INSURANCE (DI) BENEFITS HAVE BEEN REDUCED BECAUSE:
OUR RECORDS INDICATE YOU WERE PAID DISABILITY INSURANCE (DI) BENEFITS FOR A PRIOR PERIOD FOR WHICH YOU ALSO RECEIVED TEMPORARY DISABILITY WORKERS' COMPENSATION BENEFITS OR WAGES FROM ANOTHER SOURCE.
(BASIS: CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC), SECTIONS 2629 AND 2656.)
This determination is final unless you file an appeal within thirty 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 2517-55 Rev. 3 (03-18) (INTRANET)