CALFRESH NOTICE OF
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DENIAL/DISQUALIFICATION
Notice Date :
Case
FOR THE CALIFORNIA
Name
:
Number
:
FOOD ASSISTANCE PROGRAM
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.
The County is taking the following action because _________________________________________ did not follow the CalFresh work rules
for the California Food Assistance Program (CFAP).
As of ______________________ ,
■
______________________________ is denied receipt of CalFresh benefits.
■
______________________________ is disqualified from the CalFresh Program.
■
The amount of your household’s CalFresh benefits will be changed from _______________________ to _____________________.
■
Other ____________________________________________________________________________________________________
To get CalFresh benefits again, _____________________________ must be eligible. To be eligible, that person must:
Be exempt from the CFAP work rules, or
●
Take action to end the disqualification or denial.
●
■
You can take action at any time to end this disqualification.
■
You can only take action after _______________________ to end this disqualification.
You can end this disqualification at any time if you become exempt from the work rules.
If your household had other changes you will get another notice.
WHY CALFRESH BENEFITS ARE BEING STOPPED OR DENIED
■
Didn’t keep an appointment/
Didn’t give us information we asked for.
■
Didn’t go to a job.
■
Turned down a job.
■
Changed the number of hours worked to
less than 30 hours per week.
■
Quit a job.
■
Didn’t meet welfare-to-work rules for the California Work
Opportunity and Responsibility to Kids (CalWORKs) Program
■
Didn’t go on a job search
work assignment, to school, or to training that we sent you to.
■
Other.
The person listed above may also need to meet the Non-Assistance CFAP work rule. If that person is ineligible for CalFresh because they
have not met that rule for enough months to keep getting CalFresh benefits, another notice will be sent telling them what they need to do to
get CalFresh benefits again.
RULES:
These rules apply. You may review them at your welfare office.
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MPP
63-407
63-408
63-410
W&IC 18932(a)
All County Letter 99-78
Other______________
NA 995 (5/13) REQUIRED FORM - SUBSTITUTES PERMITTED
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