Form 377.7g Food Stamp Repayment Agreementfor An Intentional Program Violation (Ipv) 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 AN INTENTIONAL PROGRAM VIOLATION (IPV) ONLY
NAME
CASE NAME
ADDRESS
TERMS AND CONDITIONS
You or a member of your household broke a Food Stamp rule on purpose.
You must repay extra food stamp benefits by using one or more methods listed here:
1. Lump Sum Payment - You may repay in full the amount owed at one time with cash and/or with food stamp benefits.
2. Benefit Reduction - If you are getting food stamp benefits now, you may repay by having your household's benefits reduced for all or part
of the amount owed. Repayment by this method will be 20% of your monthly benefit or $20 each month, whichever is more.
3. Installments - You may repay the amount owed in monthly payments with cash and/or with food stamp benefits.
4. Ordered Repayment
The court or Administrative Law Judge ordered that you repay as indicated below. These repayment terms cannot be changed by
you or by the county.
If we have not already talked to you about the terms of this Agreement, or if you have any questions, call the welfare collector at
_____________________________.
After you complete and sign this Agreement, return all copies to the 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 issued. 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 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.
4. If I do not pay as agreed and the county sues me to collect the amount owed, I may also be required to pay collection costs, attorney fees,
and court costs.
5. If I do not pay, the county may take my state/federal income tax refund and/or ask the court to attach my wages or any property I own.
6. I will be subject to involuntary collection action(s) if payment is not received by the due date and the claim becomes delinquent.
7. Even if I agree to pay back what I owe, IPV penalties will apply.
Signature
Date
County
To be completed by the county:
The above signed Agreement has been accepted by_________________________________________on ________________________
Date
for ______________________ County. Payments should be made at:
(Signature of Authorized County Official)
DFA 377.7G (5/02) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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