Form Qr 377.1 - Food Stamp Notice Of Approval
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1
2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
FOOD STAMP
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
NOTICE OF APPROVAL
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 FOOD STAMP BENEFITS HAS BEEN APPROVED. Your cer tification covers the period
from ________________________ through_______________________.
We used the facts you gave us to figure your benefits. If nothing changes you will get:
$__________ for _________________________ for ____________ people.
$__________ for _________________________ for ____________ people.
$__________ for _________________________ for ____________ people.
Your food stamp eligibility starts the same day as your cash aid.
Your first month’s benefits include more than one month’s benefits because of the date your application was approved.
Your first month’s benefits were prorated from the date you filed your application.
BECAUSE YOU NEEDED FOOD STAMPS RIGHT AWAY, we did not require you to give us the following verification:
You must give us this verification before_____________________ or your food stamp eligibility will stop. You will not get another notice. If
the verification you send changes your eligibility or benefits, we will make the change. You will not get an advance notice before we take
this action.
IF YOU ALSO APPLIED FOR CASH AID, and it has not yet been approved, your food stamp benefits may be lowered or stopped without
another notice if your cash aid is approved.
COMMENTS:
Rules:
These rules apply:
You may review them at your welfare office.
QR 377.1 (4/04) REQUIRED FORM-SUBSTITUTE PERMITTED - QUARTERLY REPORTING
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