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nSlate of California / Health and Welfare Agency / Employment Development Department
NOTICE OF AUTOMATIC PAYMENT
YOUR PAYMENTS Your claimfor disabilitv benefitsis in an automaticDavment cvcle.Checkswill be issuedto vou approximately every r4 days.(lf you do not receivda'checkwithin 21 daysof your lastcheik delivery, pldasecontaatthisbffice).'Youviill not need to return certification formsfor paymentas you may have done on past claims.When it is necessary you to complete a certificatibn for 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 notify the Disabilitv to lniurancefield' office of a chahgevour claim status can be construed as fraud asaihstthe Disabilitvlnsuranceproqram providedin " and losiof benefit rights,'as and can resultiripenaltiesincludingfine, imprisonment, the California UnemploymentInsur"ance Code. IF YOU EXPECT YOUR DISABILITY BELONC-TERM, TO YOU SHOULDCONTACT THE INFORMATION LINE 1-800-772-1213 FINDOUT ABOUT AT SECURITY TO SOCIAL ADDITIONAL BENEFITS THAT MICHT BEAVAILABLE. HOW TO NOTIFYTHE DEPARTMENT When you recoverfrom your disabilityor return to work, immediatelycomplete this form and mail it field office. to the bisabilitvInsurancb
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RECOVERY TO WORK CERTIFICATION OR RETURN
THAT I RECOVERED FROM MY DISABILITY I CERTIFY OR RETURNED TO WORK ON SICN YOUR NAME
DATE S I CNE D
IF YOU CHANGE YOUR MAILINCADDRESS, INSURANCE FIELD SENDTHE DISABILITY OFFICE NOTE: YOURNAME,SOCIAL NUMBER, PHONENUMBER, AND NEWMAILINC A NOTEINCLUDINC SECURITY ADDRESS THATYOUR CHECKWILL NOT BEDELAYED. SO
DE 2587 Rev. 4 (10/95)
cu-PA130
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DEVELOPITENT DEPART}IE}IT E}IPLOYI.IENT
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P0 Box r0t02 vANNUYS CA 9rt10-0t02