Form Qr 377.2 - Calfresh Notice Of Expiration Of Certification

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH NOTICE OF EXPIRATION OF CERTIFICATION
COUNTY OF
Notice Date
:
Case Name
:
Case Number
:
Worker Name
:
Worker Number
:
Telephone Number :
Address
:
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 you how. Your
benefits may not be changed if you ask for a hearing
before this action takes place.
1. Your CalFresh Certification period will end on ________________________.
MM/DD/CCYY
2. If you want to keep getting your benefits without a break; you must file an application no later than the 15th day of the
last month of the certification period. An interview must be completed, and any proof of income, expenses, or other
information turned in no later than the end of the certification period.
3. If you have a one-month or two-month certification period, contact your worker for when your application needs to be
turned in.
4. You will get a separate letter with an interview appointment date and time. Call your worker right away if you do not
get the appointment letter within 10 days of this notice. Your appointment letter will tell you if you have a phone
interview or if you have to come into the office for your interview.
IMPORTANT RULES
To avoid a possible delay in benefits, if you file Quarterly Reports, you must turn in a completed Quarterly Report
(QR 7) by no later than the 11th of the month in which it is due.
If you do not turn in an application by the 15th day of the last month of the certification period, complete an interview,
and turn in any proof of income, expenses, or other information within 10 days of the date of the interview, you may
have to wait up to 30 days before final action is taken on your application. In addition, you may get only partial benefits
for the first month of your new certification period. You have the right to request Expedited Service (ES) if there is a
break in aid.
If you have a good reason for not recertifying on time, you should tell the county welfare department. If you have a
good reason for the delay, you may get back lost benefits.
You have the right to get an application from the county welfare department at any time and to have the county accept
your application. The application must be signed and contain at least a readable name, address, and signature or a
witness to the mark.
You or your authorized representative have the right to file a CalFresh application by turning in the form to the county
welfare department either in person, by mail, fax, e-mail, through an electronic transmission, or through an on-line
electronic application at: The length of time to deliver benefits
is calculated from the date the application is filed with the county welfare department. An application signed through
the use of electronic signature techniques or an application containing a handwritten signature and then transmitted
by fax or other electronic transmission is acceptable.
You will be given 10 days to turn in any requested information. Please tell your worker if you need help getting this
information.
RULES:
These rules apply: CalFresh MPP Section(s): 63-300.3, 63-504.25, 63-504.251, 63-504.5, 63-504.6,
63-504.61; Federal Regulation Title 7 CFR § 273.12. You may review them at your welfare office.
QR 377.2 (10/11) REQUIRED FORM - SUBSTITUTE PERMITTED

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