Form Cf 377.2b - 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.
1. Your CalFresh Certification period will end on
IMPORTANT RULES
_____________________________.
You will report again in 12 and 24 months by completing
(MM/DD/CCYY)
a form you will get from the county.
2. Please fill out the application completely and return to
If any of the following things happen, you may have to
the county by the first day of the last month of the
wait up to 30 days before final action is taken on your
certification period: ________________________.
recertification application. In addition, you may get only
(MM/DD/CCYY)
partial benefits for the first month of your new
Late applications may cause a delay in benefits.
certification period.
You do not turn in proof of any changes reported on
3. An interview is not required. You may call the county to
the recertification application before the end of your
ask for an interview if you want one. Interviews are
certification period.
done by phone unless you want an in-person interview.
You ask for an interview and do not complete an
If you need help due to a disability; please tell the
interview within 10 days before the end of the
county right away.
certification period.
4. If you ask for an interview, you will get a separate letter
You are told an interview is required and do not
with interview appointment date and time.
complete an interview within 10 days of the end of
of the certification period.
5. If you do not keep the scheduled appointment, it is your
You have the right to get an application from the county
responsibility to reschedule it.
and to have the county accept your application. The
application must be signed and contain at least your
6. If you are reporting changes such as income and
name, address, and signature.
expenses, please include proof with your application.
You, or your authorized representative, have the right to
Proof of any changes must be turned in no later than
file a CalFresh application by turning in the form to the
the end of your certification period. Please tell the
county in person, by mail, by fax or by other
county if you need help getting this information.
transmission available in your county (e-mail or on-line
electronic application at: ).
7. Based on the information you turn in, the county may
The length of time to deliver benefits is calculated from
need to interview you.
the date the application is filed with the county.
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 377.2B (6/17) REQUIRED FORM - SUBSTITUTE PERMITTED
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