Form Temp Na 1232 - Calfresh Notice Of Action Ebt Account
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1
2CALFRESH
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION
EBT ACCOUNT
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 REACTIVATED
ACCOUNT DEACTIVATED
■ ■
OUR RECORDS SHOW THAT YOU HAVE NOT USED YOUR
On __________________________, the county started access
CALFRESH ELECTRONIC BENEFIT ACCOUNT FOR OVER 135
to your CalFresh electronic benefit account.
DAYS.
If you have lost your card call 1 - 877 - 328-9677. If you need help
■ ■
using your EBT card, call your county worker.
If you do not use your CalFresh benefit card by
_____________________________ , the county will stop access
to your electronic CalFresh benefits. You can stop this action by
This Notice:
Does not change your eligibility to benefits;
using your CalFresh benefit card.
●
Does not change your responsibility to report changes that affect
●
your eligibility; and
OUR RECORDS SHOW THAT YOU HAVE NOT USED YOUR
CALFRESH ELECTRONIC BENEFIT ACCOUNT FOR OVER 180
Does not change your cash aid or Medi-Cal benefits. If these
●
DAYS.
benefits change, you will get a separate notice.
■ ■
On _______________________, the county stopped access to
your CalFresh benefits. Call your County Worker to activate your
electronic CalFresh benefit account again.
IF YOU HAVE ANY CALFRESH ELECTRONIC BENEFIT THAT HAS
NOT BEEN USED FOR 365 DAYS, THAT UNUSED BENEFIT WILL
BE REMOVED FROM YOUR EBT ACCOUNT AND CANNOT BE
RESTORED.
Rules: These rules apply: You may review them at your welfare
office. MPP 16-120.
Page 1 of ____
TEMP NA 1232 (6/11) REQUIRED FORM - SUBSTITUTE PERMITTED
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