ssrf: 575'13'2719 ilAilE: DANIEL K KAUITE
CLAIIiI EFFECTIVE DATE:
ooSr
25
|IATE ISSUEDz LOI?AIOA
LOltttoa
EDD
serving
the peopte
or calirornia
-
YOUR PAYMENTS
Your claim for disabilitv benefits is in an automatic Davment cvcle. Checks will be issued to vou
approximately every r4 days. (lf you do not receivd a'check within 21 days of your last cheik delivery,
pldase contaat thisbffice).'You viill not need to return certification
formsfor payment as you may
have done on past claims. When it is necessary
for you to complete a certificatibn
form, one will'be
provided.
YOUR RESPONSIBITITY
To prevent an overpayment on your claim, you must immediately notify the Department if you
recbver from your ilisabilitv or ieturn to wdrk. Failure
to notify the Disabilitv
lniurance field'
office of a chahge vour claim status can be construed as fraud asaihst the Disabilitv lnsurance proqram
and can result iripenalties including fine, imprisonment, and losiof benefit rights,'as providedin "
the California Unemployment Insur"ance
Code.
IF YOU EXPECT
YOUR DISABILITY
TO BE LONC-TERM,
YOU SHOULD CONTACT THE
SOCIAL SECURITY
INFORMATION
LINE AT 1-800-772-1213
TO FIND OUT ABOUT
ADDITIONAL BENEFITS
THAT MICHT BE AVAILABLE.
HOW TO NOTIFY THE DEPARTMENT
nSlate of California / Health and Welfare Agency / Employment Development Department
NOTICE OF AUTOMATIC PAYMENT
RECOVERY OR RETURN TO WORK CERTIFICATION
RECOVERED FROM MY DISABILITY OR RETURNED TO WORK ON
DATE
SICNED
When you recover from your disability or return to work, immediately complete this form and mail it
to the bisabilitv Insurancb
field office.
I CERTIFY THAT I
SICN
YOUR NAME
NOTE:
IF YOU CHANGE YOUR MAILINC ADDRESS,
SEND THE DISABILITY
INSURANCE FIELD OFFICE
A NOTE INCLUDINC YOUR NAME, SOCIAL SECURITY
NUMBER, PHONE NUMBER, AND NEW MAILINC
ADDRESS O THAT YOUR CHECK WILL NOT BE DELAYED.
DE 2587 Rev. 4 (10/95)
cu-PA130
RETURN THIS FORM TO
ll,l,,',,ll,l,,l,,,llll,,,ll',,,1,,111,,,,,1,111,,,,,1,11,,,11
E}IPLOYI.IENT
DEVELOPITENT
DEPART}IE}IT
P0 Box r0t02
vAN NU