Form Na 1240 - Notice Of Action - Calfresh Overissuance And Dormant Ebt Account

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NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CalFresh Overissuance and
Notice Date :
Case
Dormant EBT Account
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.
ACCOUNT OVERISSUANCE
YOU MUST:
Our records show you have an outstanding overissuance of CalFresh
Contact the county within 10 days after the date this notice was mailed to
benefits in the amount of $ _______________________________ .
you if you do not want your CalFresh benefits to be applied to your
overissuance. Your CalFresh benefits will be used to repay your
Our records also show that you have not used your CalFresh electronic
overissuance if the county does not hear from you.
benefit transfer (EBT) account for over 180 days.
BECAUSE YOU HAVE NOT USED YOUR EBT ACCOUNT FOR 180
DAYS, CALFRESH BENEFITS FROM YOUR EBT ACCOUNT WILL BE
USED TO REPAY YOUR CALFRESH OVERISSUANCE UNLESS YOU
CONTACT US WITHIN 10 DAYS AFTER THE DATE THIS NOTICE WAS
MAILED TO YOU.
Rules: These rules apply; you may review them at your welfare
office: MPP 16-120.12 and 16-750.12.
Page 1 of ____
NA 1240 (4/13) REQUIRED FORM - SUBSTITUTE PERMITTED

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