Form Cf 377.2c - Calfresh Notice Of Expiration Of Certification For Households With Only Elderly And/or Disabled Members
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1
2CALFRESH NOTICE OF
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EXPIRATION OF CERTIFICATION
Notice Date:
FOR HOUSEHOLDS WITH ONLY
Case Name:
Case Number:
ELDERLY AND/OR DISABLED
Worker Name:
MEMBERS
Worker Number:
Telephone Number:
Address:
(ADDRESSEE)
Need help or have 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.
SPECIAL NOTE
IMPORTANT RULES
●
We told you that a recertification interview is not required.
You will report again in 6, 12, and 18 months by
Based on the changes you have told county about, you
completing a form you will get from the county.
●
now need to complete a recertification interview.
If any of the following things happen, you may have to
wait up to 30 days before final action is taken on your
1. Your CalFresh Certification period will end on
recertification application. In addition, you may get only
_____________________________.
partial benefits for the first month of your new
(MM/DD/CCYY)
certification period.
●
2. An interview is required. Interviews are done by phone
You are told an interview is required and you do not
unless you want an in-person interview. If you need
complete an interview within 10 days of the end of
help due to a disability, please tell the county right
the certification period.
●
away.
You do not turn in any proof of income, expenses,
NEXT STEPS
or other change information within 10 days of the
1. Please fill out the application completely and return to
date of the interview.
●
the county by the first day of the last month of the
You do not turn in proof of any changes reported on
certification period: ________________________.
the recertification application before the end of your
(MM/DD/CCYY)
certification period.
●
Late applications may cause a delay in benefits.
You have the right to get an application from the county
and to have the county accept your application. The
2. You will get a separate letter with an interview
application must be signed and contain at least your
appointment date and time. Call your worker right away
name, address, and signature.
●
if you do not get the appointment letter within 10 days
You, or your authorized representative, have the right to
of this notice.
file a CalFresh application by turning in the form to the
county in person, by mail, by fax or by other
3. If you do not keep the scheduled appointment, it is your
transmission available in your county (e-mail or by on-line
responsibility to reschedule it.
electronic application at: ).
The length of time to deliver benefits is calculated from
4. If you are reporting changes such as income and
the date the application is filed with the county.
expenses, please include proof with your application.
Proof of any changes must be turned in no later than
the end of your certification period. Please tell the
county if you need help getting this information.
Rules: These rules apply: CalFresh MPP Sections: 63-300.3,
63-504.25, 63-504.251, 63-504.6, 63-504.61. You may review
them online at cdss.ca.gov or at your local county office.
CF 377.2C (6/17) REQUIRED FORM - SUBSTITUTE PERMITTED
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