Form Cf 1239 Calfresh Notice Ofapproval/denial/terminationtransitional Benefits
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1
2CALFRESH NOTICE OF
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPROVAL/DENIAL/TERMINATION
TRANSITIONAL BENEFITS
Notice Date :
Case
Name
:
Case
Number
:
Worker
Name
:
Worker
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.
■ ■
■ ■
Denial/Withdrawal
Approval
As of ______________________________, your CalFresh benefits are
As of _________________, the CalFresh recertification you asked for
MM/DD/CCYY
MM/DD/CCYY
during the first 4 months of Transitional CalFresh benefits was not
$ __________ each month.
approved. Your current Transitional CalFresh benefit will continue until
the end of the Transitional CalFresh benefit period.
Because your CalWORKs case has been closed, you will get
Here’s Why:
Transitional CalFresh benefits. You will get Transitional CalFresh
benefits starting _______________ and ending ________________.
■ ■
You have withdrawn your request for recertification for regular
MM/CCYY
MM/CCYY
CalFresh benefits.
This replaces your previous certification period.
■ ■
You did not give us the information we asked for within 10 days of
the date requested.
Your Transitional CalFresh benefits will end after 5 months unless your
■ ■
household recertifies.
You did not complete your scheduled interview.
■ ■
Other (see below):
Reporting:
You are encouraged to report if you change your address. Households
that get Transitional CalFresh benefits do not have to turn in a reporting
form.
■ ■
Termination
Recertification:
As of _______________________, your current Transitional CalFresh
MM/DD/CCYY
You will get a notice when it is time to recertify at the end of the
benefit period will end.
5-month Transitional CalFresh period.
Here’s Why:
You may ask to recertify for regular CalFresh at any time during
●
the Transitional CalFresh period. If you ask to recertify during the
■ ■
Your application for CalWORKs has been approved.
first four months of the Transitional CalFresh period and the
■ ■
regular CalFresh benefits are lower than the current Transitional
Your application for CalFresh has been approved.
■ ■
CalFresh amount, you may withdraw your request for
Your CalWORKs and/or CalFresh benefits have been restored.
■ ■
recertification.
Other (see below):
If you apply and are approved for CalWORKs and regular
●
CalFresh, you will have a new certification period. Eligibility for
Transitional CalFresh will end when the CalWORKs and regular
CalFresh benefits are approved, even if your 5 months have not
ended.
Rules: These rules apply: MPP § 63-504.6, MPP § 63-504.13.
You may review them at your welfare office.
Page 1 of ____
CF 1239 (5/13) REQUIRED FORM - SUBSTITUTE PERMITTED
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