DI / DE 2517-37

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 claim for disability benefits has been denied from MM/DD/YY through when eligible because:
You were in custody because of a violation of law or criminal conviction and were unavailable to work. (Basis: Section 2680, California Unemployment Insurance Code (CUIC))

How to File an Appeal

You have the right to file an appeal. This determination is final unless you appeal within 30 days from the Mailing Date of this notice.

You may appeal by giving a detailed statement on why you disagree with our decision. Include your DI Claim Identification (ID) Number and mail your statement to the return address on the top of this page.

For more information on disability appeals, visit edd.ca.gov/en/disability/appeals 

State of California / Employment Development Department (EDD)

DE 2517-37 Rev. 4 (09-24) (INTRANET)