STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALFRESH NOTICE OF
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPROVAL/DENIAL/TERMINATION
Notice Date:
WORK INCENTIVE NUTRITIONAL
Case Name:
Case Number:
SUPPLEMENT (WINS) BENEFIT
Worker Name:
Number/ID:
Telephone:
24 Hour Information:
Address:
(ADDRESSEE)
Questions? Ask your Worker or call the number above.
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.
I
I
Approval
Termination
As of
, your WINS benefit is being
As of
, you will receive a ten dollar
stopped.
MM/DD/CCYY
MM/DD/CCYY
($10) WINS food supplement benefit each month. You are
receiving this benefit because you:
Here’s Why:
I
Your legal guardianship was terminated for your only
Are a CalFresh household, but not receiving California Work
Opportunity and Responsibility to Kids (CalWORKs) or Tribal
qualifying child.
Temporary Assistance to Needy Families (TANF);
I
You moved out of the State of California.
Have a child under the age of 18 in the home; and
I
Your application for CalWORKs has been approved.
Have at least one parent/caretaker in the household who is
receiving CalFresh, who meets the TANF definition of a
I
Your CalFresh benefits have been discontinued.
“work-eligible individual,” and is participating in enough hours
I
Your only qualifying child has moved out of the house.
in eligible work activities that meet the federal TANF
requirements.
I
Your only qualifying child has reached 18 years of age.
I
Your work hours have fallen below the minimum required for
Note: Recertification
You will get a notice when it is time to recertify your CalFresh. At
WINS eligibility.
that time your continuing eligibility for WINS will be reviewed.
I
Other (see below):
If you apply and are approved for CalWORKs your WINS benefit
will be discontinued.
I
Denial
You are not eligible to receive a WINS benefit. This will not affect
your CalFresh benefits.
Here’s Why:
I
The child you are caring for is 18, or over.
I
The child you were caring for no longer lives with you.
I
A legal guardianship has not been established for the child.
I
Your work hours are below the minimum required for WINS
eligibility.
I
Your application for CalFresh has been denied.
I
Other
Rules: These rules apply: ACL 13-71, ACIN I-14-14,
Welfare & Institutions Code 15525.
You may review them at your welfare office.
WINS 1239 (5/14) REQUIRED FORM - SUBSTITUTE PERMITTED
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