SDI DATA SLIP
Disability website : https://portal.edd.ca.gov/WebApp/Login?resource_url=https%3A%2F%
Date
*
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Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Social Security #
Receipt #
Claim #
Date of Injury
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Month
-
Day
Year
Date
Disability start Date
-
Month
-
Day
Year
Date
Comments:
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Should be Empty: