Form Temp Na 1238 - Food Stamp Notice Of Action Ebt Account Adjustment

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Food Stamp Notice of Action
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EBT Account Adjustment
Notice Date :
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.
ACCOUNT ADJUSTED (By Retailer)
ACCOUNT ADJUSTMENT REVIEW:
The county has denied your request to have $ __________ added to
On_____________, your electronic food stamp benefit account
your Electronic Benefit Transfer (EBT) Food Stamp account.
will have $ ___________________ removed from your balance.
HERE’S WHY:
HERE’S WHY:
A system error happened when using your electronic food stamp
A system error did not happen when using your electronic food stamp
benefit account:
benefit account:
Date:
Date:
Time:
Time:
Location:
Location:
Amount:
Amount:
Other:
Other:
IMPORTANT
Your benefits in your EBT account may not be removed if you ask for
a hearing before this action takes place.
This Notice:
If you are required to repay benefits and you do not have enough
does not change your eligibility to benefits;
benefits in your account to repay the amount of the error, we will take
does not change your responsibility to report changes that affect
it out of your next month’s benefits.
your eligibility; and
This Notice:
does not change your cash aid or Medi-Cal benefits--if cash aid or
does not change your responsibility to report changes that affect
Medi-Cal benefits change you will get a separate notice.
your eligibility; and
does not give you aid paid pending rights because of an account
does not change your cash aid or Medi-Cal benefits--if cash aid
adjustment denial.
or Medi-Cal benefits change, you will get a separate notice.
does not change your eligibility to benefits.
Rules: These rules apply: You may review them at your welfare office.
MPP 16-705, and 16-705.32.
Page 1 of ____
TEMP NA 1238 (7/04) REQUIRED FORM - SUBSTITUTE PERMITTED

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