Form Dfa 377.11 Food Stamp Notice Ofdiscontinuance

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FOOD STAMP NOTICE OF
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DISCONTINUANCE
Notice Date :
Case
(Failure to meet the Able-Bodied Adults
Name
:
Without Dependents (ABAWDs) Work Rule)
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.
_______________________________ , as of ______________________ ,
Employed or self-employed at least 30 hours per week or receiving
(NAME)
(DATE)
weekly earnings at least equal to the federal minimum wage multiplied
by 30 hours;
your food stamps will be stopped because you got food stamps for
Going to school at least half-time;
___________________ , _________________ , and ________________
Pregnant; or
(MONTH/YEAR)
(MONTH/YEAR)
(MONTH/YEAR)
Living in a food stamp household that contains a minor child even if
without meeting the Able-Bodied Adults Without Dependents (ABAWD)
the minor child is not eligible for food stamps.
work rule.
YOU WON’T LOSE YOUR FOOD STAMPS IF
The amount of your food stamps will change from $ _____________ to
by ____________________ , you
$ _______________ .
(DATE)
Show verbal or written proof that you are meeting the ABAWD work
IF YOU LOSE YOUR FOOD STAMPS, YOU CAN GET FOOD STAMPS
rules.
BACK IF
Are excused (see list on left side “TO BE EXCUSED FROM THE
by __________________ , you
WORK RULES”).
(DATE)
Have a reason (i.e., were temporarily ill, were caring for a sick
household member, had a household emergency, had no
Show proof that you are meeting the following ABAWD work rules.
transportation available, had problems speaking, reading, or writing
English) for not meeting the work rules.
For at least 20 hours per week, you must either;
Work,
Start meeting the rule you failed to meet (see work rule above or call
your worker).
Go to school or training,
Go to a combination of school, training and work, or
Go to workfare for the number of hours determined by the
36-MONTH PERIOD
county.
During a 36 month period you can only get food stamps for three
Meet one of the excuses from the work rules below.
months unless you meet the ABAWD work rule.
You can get food stamps for another three months without meeting the
Have a temporary reason (such as you were ill, were caring for a sick
ABAWD work rule if you meet certain conditions.
household member, had a household emergency, had no
transportation available, had problems speaking, reading, or writing
HERE’S HOW TO GET FOOD STAMPS BACK
English).
You may get food stamps back if you meet one of the ABAWD work
You may apply at any time if you become excused from the work rule
rules listed above during a period of 30 days.
or after ________________ , when your 36-month calendar ends.
You may apply at any time if you become excused from the work rule
(DATE)
or after __________________________ , when your 36-month
(DATE)
calendar ends.
TO BE EXCUSED FROM THE WORK RULES, YOU MUST BE
Under 18 or 50 years of age or older;
Physically or mentally unfit for employment;
Meeting the CalWORKs Welfare-to-Work rules;
Caring for an injured or sick person who will need help for more than
30 days;
Participating in a alcohol or drug treatment program that keeps you
from working 30 hours or more per week;
RULES: These rules apply. You may review them at your welfare office.
Getting or have applied for Unemployment Insurance benefits;
MPP Section
63-410;
Other _______________________ .
DFA 377.11 (9/04) REQUIRED FORM - SUBSTITUTES PERMITTED

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