Form Cf 37 - Recertification For Calfresh Benefits Page 6
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11STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State
or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, (AD 3027) found online at , and at any
USDA office, or contact your County’s Civil Rights Coordinator, or write a letter addressed to USDA and
provide in the letter all of the information requested in the form or write to California Department of So-
cial Services (CDSS) address below. To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by:
(1) mail:
U.S. Department of Agriculture
CDSS
Office of the Assistant Secretary for Civil Rights
Civil Rights Bureau
P.O.BOX 944243, M.S. 8-16-70
1400 Independence Avenue, S.W.
Sacramento, CA 94244-2430
Washington D.C. 20250-9410
1-866-741-6241 (Toll Free)
(2) fax:
(202) 690-7442; or
(3) email:
program.intake@usda.gov
This institution is an equal opportunity provider.
Case File Reviews: Your case may be selected for additional review to ensure that your eligibility
was correctly figured. You must cooperate fully with the county, state, or federal personnel in any
investigation or review, including a quality control review. Failure to cooperate in these reviews could
result in loss of your benefits.
Work Rules for CalFresh: The County may assign you to a mandatory work program. If you do not
participate when required by the County, your benefits could be reduced or stopped. You may not be
eligible to CalFresh if you have recently quit a job without a good reason.
EBT Usage: Any use of your EBT card by you, a household member, your authorized representative,
or anyone you voluntarily give your EBT card and PIN to will be considered approved by you and any
benefits taken from your account will not be replaced.
CalFresh Program Rules Page 6 – Please take and keep for your records.
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PROGRAM RULES PAGE 6 OF 7
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