Form Cf 377.7e1 Calfresh Repayment Agreementfor Administrative Errors Only
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NUMBER
CALFRESH 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 CalFresh benefits. You must repay
extra CalFresh 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 CalFresh benefits.
2. Benefit Reduction - If you are getting CalFresh benefits now, you may repay by having your household's benefits reduced for all or part of
the amount owed. You may wish to talk to us about the amount to be reduced.
3. Installments - You may repay the amount owed in monthly payments with cash or with CalFresh 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 CalFresh benefits
through the mail with this Agreement form. 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 CalFresh benefits 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 CalFresh 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 CalFresh 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.
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.
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)
CF 377.7E1 (1/14) AE O/I OCCURRING ON/AFTER 10/1/96 - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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