Form De 6315d - Notice Of Right To Continue Disability Benefits Pending Appeal
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1
2SSN:
CED:
Mailing Date:
Notice of Right to Continue Disability
Form Code:
Benefits Pending Appeal
(Basis: California Code of Regulations, title 22, section 2706.5)
IF YOU DO NOT WISH TO APPEAL, DISREGARD THIS NOTICE.
IF YOU DECIDE TO APPEAL, COMPLETE THIS FORM AND RETURN IT WITH A LETTER OF APPEAL
OR THE COMPLETED APPEAL FORM PROVIDED TO YOU.
If you file a timely appeal to the Notice of Determination, choose one of the options below by checking the
appropriate box.
I request the SDI program pay me disability benefits pending the decision on my appeal. To receive these
benefits, I understand that I must continue to file continued claims. I also understand that if the decision on the
appeal is against me, I may be required to repay those benefits, unless it is found I received the overpayment
without fault on my part and that it would be against equity and good conscience to require repayment. In addition,
if I choose to pursue this adverse decision to the Appeals Board, SDI will not continue to pay me.
OR
I request the SDI program withhold disability benefits pending the decision on my appeal. I understand
that I must still continue to file continued claims until I either recover or return to work. I also understand that if I
win the appeal, I will be paid only those benefits for any period of eligibility for which I have submitted certification
and/or medical extension forms to SDI.
SIGN, DATE, AND ATTACH THIS FORM TO YOUR LETTER OF APPEAL OR APPEAL FORM AND MAIL BOTH
TO THE OFFICE SHOWN BELOW.
Sign Your Name:
Date:
(800) 480-3287
Disability Insurance Office
Telephone:
P.O. Box
DE 6315D Rev. 4 (3-99) (INTERNET)
CU
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