Form Dfa 377.7e Food Stamp Repayment Agreementfor Administrative Errors Only
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NUMBER
FOOD STAMP REPAYMENT AGREEMENT
WORKER
FOR ADMINISTRATIVE ERRORS ONLY
NAME
CASE NAME
ADDRESS
TERMS AND CONDITIONS – The County Welfare Department made a mistake in the amount of your food stamps. You do not have to
agree to benefit reduction unless you want to repay this way. If you do, you must sign this agreement. See attached REPAYMENT NOTICE
(DFA 377.7D).
You may repay extra food stamp benefits by using one or more methods listed here:
1. Lump Sum Payment - You may repay all or part of the amount
4. Ordered Repayment
owed at one time with cash and/or food stamp benefits.
The court or Administrative Law Judge ordered that you
repay as indicated below.These repayment terms cannot be
2. Benefit Reduction - If you are getting food stamp benefits now,
changed by you or by the county.
you may repay by having your household's benefits reduced for
If we have not already talked to you about the terms of this
all or part of the amount owed. You may wish to talk to us about
Agreement, or if you have any questions, call the welfare collector at
the amount to be reduced.
_____________________________.
3. Installments - You may repay all or part of the amount owed in
After you complete and sign this Agreement, return all copies to the
monthly payments with cash and/or food stamp benefits.
county in the envelope provided. Do not send cash or food stamp
benefits through the mail with this Agreement. When approved by
the county, a signed copy of this Agreement will be sent to you.
AGREEMENT
I, _______________________________________ , understand this Agreement is between me and __________________ County because
extra food stamps in the amount of $ ___________ were overissued due to the county’s error. I agree to repay this amount by the method(s)
checked below:
Lump Sum Payment
I will repay by a lump sum cash payment of $____________due on_____________________.
I will repay by a lump sum food stamp benefit payment of $__________due on_____________________.
Benefit Reduction
I will repay by having my household's benefits reduced by $____________ each month, beginning ______________.
Installments
I will repay by monthly cash payments of $___________ due on the_________ day of each month beginning _______________.
I will repay by monthly food stamp benefit payments of $___________ due on the________ day of each month beginning
____________________.
I also understand and agree that:
1.
My repayment schedule is based on my current ability to pay as figured by the county. Any changes in my ability to pay may change my
monthly payments.
2.
If anything changes I may ask the county to refigure the repayment terms checked above.
3.
If I do not pay as agreed and I do not get a new payment schedule, the county may ask that the total amount owed be paid now.
Signature
County
Date
To be completed by the county:
The above signed Agreement has been accepted by_________________________________________on ________________________
for ________________________ County. Payments should be made at:
(Signature of Authorized County Official)
DFA 377.7E (7/04) USE FOR AE O/I OCCURRING PRIOR TO 10/1/96 - RECOMMENDED FORM
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