Form Dfa 377.10 Food Stamp Notice Ofdenial/disqualification
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1
2FOOD STAMP NOTICE OF
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DENIAL/DISQUALIFICATION
Notice Date :
Case
(Failure to meet the Food Stamp Program
Name
:
work rules)
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
(ADDRESSEE)
Questions? Ask your Worker.
State Hearing: If you think this action is wrong, you can
ask for a hearing. The back of this page tells how. Your
benefits may not be changed if you ask for a hearing
before this action takes place.
The county is taking the following action because __________ did not
TO BE EXCUSED FROM THE WORK RULES, YOU MUST BE
follow the Food Stamp Program work rules (listed below).
Under 16 or 60 years of age or older;
16 or 17 and not the head of your food stamp household;
You are
Denied /
Disqualified for 1
3
or 6
months.
Physically or mentally unfit for employment;
Meeting the CalWORKs Welfare-to-Work rules;
The penalty will end on ________________________ .
(DATE)
Caring for a child under six or an injured or sick person;
The amount of your household’s food stamps will be changed from
Participating in an alcohol or drug treatment program that keeps you
$ ____________ to $ ____________.
from working 30 hours or more a week.
Getting or have applied for Unemployment Insurance benefits.
REASON YOU WILL NO LONGER GET FOOD STAMPS IS BECAUSE
Employed or self-employed at least 30 hours per week or receiving
YOU FAILED TO MEET ONE OF THE WORK RULES BELOW, YOU DID
weekly earnings at least equal to the federal minimum wage multiplied
NOT;
by 30 hours;
Going to school at least half-time;
Register for work.
HERE’S HOW TO GET FOOD STAMPS BACK
Keep your job or keep working at least 30 hours a week.
Starting ___________________ , you can get food stamps if you are
(DATE)
Par ticipate in a workfare, job search, or other work related
assignment.
eligible, and agree to meet the Food Stamp Program work rules.
Give the county information about your work history if you are able to
If you become excused from the Food Stamp Program work rules, you
work.
may apply at any time. (see excused list above).
Report to an employer for work.
COMMENTS
Accept a good job offer.
Par ticipate in the Unemployment Insurance Program work
requirement.
Par ticipate in the CalWORKs Welfare to Work Program work
requirement.
Please call us if you think you have a reason for not meeting
the work rule.
HOW TO KEEP FROM LOSING YOUR FOOD STAMPS
By ________________________ , you must
(DATE)
Show verbal or written proof that you are meeting the Food Stamp
Program work rules.
Have a good reason for not meeting the work rule.
Be excused (see the following list).
RULES: These rules apply. You may review them at your welfare office.
MPP Section
42-721;
63-407;
63-408;
Other:____________________ .
DFA 377.10 (6/04) REQUIRED FORM - SUBSTITUTES PERMITTED
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