Form Cf 377.7a - Notice Of Administrative Disqualification
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1
2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF
ADMINISTRATIVE DISQUALIFICATION
Notice Date
:
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone
:
Address
:
Questions? Ask your Worker.
(ADDRESSEE)
State Hearing: You cannot appeal
the disqualification action in a state
hearing. If you think the new amount
of CalFresh benefits for the other
members of your household is
wrong, you can ask for a hearing.
The back of this page tells how.
Most often the new amount will not
change unless the hearing decision
changes it.
DISQUALIFICATION ACTION
END OF DISQUALIFICATION
The following action disqualified you from the CalFresh Program:
•
If you were disqualified for 12 or 24 months and still live in the
■ ■
same CalFresh household, you should begin to get CalFresh
A state hearing decision found you committed an intentional
automatically the month after the end date listed above. If that
program violation.
does not happen, you should call your worker or return the
■ ■
attached form.
A court decision found you committed an intentional program
•
If you live in a new CalFresh household, you must request to be
violation.
added to the household after the end date listed above. You or
■ ■
your authorized representative have the right to file a CalFresh
You signed a Disqualification Consent Agreement on_________.
application by turning in the form to the county welfare department
■ ■
You signed an Administrative Disqualification Hearing Waiver
either in person, by mail, fax, e-mail, through an electronic
transmission, or through an on-line electronic application at:
on_____________________.
http/
■ ■
You were disqualified from the CalFresh Program
•
If you do not live in a household that gets CalFresh at the end of
the disqualification period, you must reapply for CalFresh. You or
in__________________________.
your authorized representative have the right to file a CalFresh
(LOCATION)
A copy of the above action was sent or given to you. If a state
application by turning in the form to the county welfare department
hearing decision found you committed an intentional program
either in person, by mail, fax, e-mail, through an electronic
transmission, or through an on-line electronic application at:
violation, the state or federal government may still prosecute you in
http/
court.
•
You may return the form on the next page to request that your
CalFresh be restored.
DISQUALIFICATION PENALTY
•
If you were permanently disqualified from the CalFresh program,
The disqualification penalties are 12 months for the first violation, 24
you cannot have your CalFresh restored.
months for the second violation, and permanent disqualification for
the third violation. There are separate penalties if you break these
NOTICE TO THE OTHER MEMBERS OF YOUR HOUSEHOLD
■ ■
rules:
Because________________________was disqualified from the
•
If you are found guilty in any court of law of having traded
CalFresh Program:
CalFresh benefits for firearms, ammunition, or explosives, you
■ ■
Your CalFresh benefits will change from $____________to
can be disqualified forever for the first violation.
$______________________as of____________________.
•
If you are found guilty of having traded CalFresh benefits for
■ ■
But since you reported a change, your CalFresh
controlled substances, you can be disqualified for 24 months for
benefits will be different. The enclosed Notice of
the first violation and forever for the second violation.
Change shows the amount you will get.
•
If you are found guilty of having traded or sold CalFresh benefits
■ ■
Your CalFresh benefits will stop as of________________.
worth $500 or more, you can be disqualified forever.
As a result of this disqualification, your income is too high.
•
If you are found to have filed more than one application at the
You may reapply when the disqualification period ends or if
same time and have given false identification or residence
circumstances change.
information, you can be disqualified for ten years.
■ ■
Your certification period has ended. You may reapply at any
This is your_____________________ violation, which means:
time. Your CalFresh benefits may be different because
■ ■
______________________ was disqualified.
You cannot get CalFresh benefits for___________months,
COMMENTS:
from________________to_________________.
■ ■
You have been permanently disqualified from the CalFresh
Program, as of_________________.
Rules: These rules apply. You may review them at your welfare office:
MPP Sections 20-300.221(c), 20-300.3, 22-003.11, 63-804.1, 63-805.1.
CF 377.7A (2/14) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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