Form Na 1267 - Calfresh Informing - Notice Of Receiving Intercounty Transfer
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1
2CALFRESH INFORMING
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF RECEIVING
Notice Date :
Case
INTERCOUNTY TRANSFER
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.
___________________________ County has transferred your
CalFresh case to our county.
This letter has your new case number, worker’s name and telephone
number. Please refer to this letter when you contact us.
You will get the CalFresh benefits listed below:
$ ____________ effective __________________ for ______ person(s).
MM/DD/CCYY
You will receive a new electronic benefits transfer card (EBT) for the
benefits listed above. If you don’t receive a new EBT card, please
contact our office.
If you still have benefits on your EBT card from your old county, you can
use that card until those benefits are gone. You will not be able to use
your old EBT card for the benefits listed above.
You must report changes that could affect your eligibility on your periodic
report and to the worker listed in this notice.
You must complete the forms required for your CalFresh annual
recertification when sent to you.
Rules: These rules apply: All County Letter 11-22 and Welfare &
Institutions Code § 11053.2. You may review them at your welfare
office.
Page 1 of ____
NA 1267 (4/13)
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