DI / DE 2578X

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo
Mailing Date:
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Claim ID:
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Claimant Name:
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CED:
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INSTRUCTIONS FOR FILING A CLAIM FOR REDUCED DISABILITY BENEFITS

 
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Disability Insurance Office
‎PO Box #
City, State 99999-9999
1-866-352-7675
If you are filing a claim for disability benefits reduced by the amount of temporary workers' compensation you have received or are entitled to receive for the same period, section 2708.1-1 of Title 22 of the California Administrative Code requires that you return the following certification IF you do not wish to obtain a certificate of a doctor to support your claim:
  1. The name and address of the physician/practitioner treating me for my industrial injury is:
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    Print or Type Doctor's Name
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    Street
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    City
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    State
  2. The first day I was examined by or came under the care of a physician/practitioner for this period of unemployment and disability was:
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    Month
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    Date
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    Year
  3. I certify that the foregoing statements are to the best of my knowledge and belief is true, correct, and complete. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law and that such violation is punishable by imprisonment or fine or both.
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    Your Signature (Do Not Print)
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    Date Signed: Month
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    Date
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    Year
Your claim ID:
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No further action can be taken on your claim without a doctor's certificate unless you complete this form and return it to the address shown on the form.
 
State of California
EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD)

DE 2578X Rev. 5 (8-21) (INTRANET)