DI / DE 2525A

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
ANY CITY CA 99999-9999
FIRSTNAME M LASTNAME
‎1234 ANY ST
ANY CITY CA 99999-9999
 

NOTICE OF EXHAUSTION OF DISABILITY BENEFITS

 
MAILING DATE:
MM/DD/YY
You have been issued the last benefit payment you can receive from your present claim for Disability Insurance (DI) because your benefits are exhausted.
Basis: California Unemployment Insurance Code (CUIC), Section 2653.
IMPORTANT. If your disability is permanent and is expected to continue, you may wish to contact your nearest Federal Social Security Office or the State Department of Rehabilitation (DOR) to discuss your eligibility for benefits and/or assistance.

State of California / Employment Development Department (EDD)

DE 2525A Rev. 3 (3-18) (INTRANET)