Form Dfa 390 Notice Of Approval/denialfor Disaster Calfresh
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1
2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF APPROVAL/DENIAL
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
FOR DISASTER CALFRESH
Case
Name
:
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.
■ ■
Your application for Disaster CalFresh benefits has been approved. Your certification covers the disaster benefit period from
___________________ through ____________________.
Your one time Disaster CalFresh benefit allotment for a household of __________ is ___________________.
■ ■
Your application for Disaster CalFresh benefits has been denied because of the following:
■ ■
You failed to appear for the Disaster CalFresh interview.
■ ■
You did not live or work in the disaster area at the time of the disaster.
■ ■
Your income and resources exceed the income and resource limits for the Disaster CalFresh Program.
■ ■
Other ____________________________________________________________________________.
The table below shows how we calculated the Disaster CalFresh benefit for your household. We used the information you gave
us on the Application for Disaster CalFresh (DFA 385) to determine your household’s Disaster CalFresh benefit amount.
Disaster CalFresh Benefit Calculation:
a. Anticipated Income
$
b. Accessible Cash
(+)
Resources
(=)
c. Total disaster period
income = (a+b)
d. Total allowable disaster
(-)
related expenses
e. Accessible disaster period
(=)
income = (c-d)
f.
Maximum Disaster Income
Household
Limit for Household size
size:
(use information from
Disaster Table)
If (e) is equal to or less than (f), the household is eligible.
g. Disaster Allotment
(from Disaster Table)
h. Regular allotment already
(-)
received (if any)
(=)
i.
Net disaster allotment (g-h)
Rules: These rules apply. MPP 63-900
You may review them at your welfare office.
DFA 390 (9/11) REQUIRED FORM -NO SUBSTITUTE PERMITTED
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