DI / DE 2517-32

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
 

Continuous Claim Determination

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
THE RECENT DISABILITY INSURANCE (DI) CLAIM YOU FILED HAS BEEN DETERMINED TO BE A CONTINUATION OF YOUR PRIOR DISABILITY BENEFIT PERIOD WHICH BEGAN MM/DD/YY. THE MAXIMUM BENEFIT AMOUNT OF YOUR CLAIM PERIOD WAS ‎$00,000.00. WITH THIS PAYMENT YOUR BALANCE IS ‎$00,000.00.
BASIS: CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC), SECTION 2608.
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 2517-32 Rev. 4 (03-18) (INTRANET)