63-103 DEFINITIONS--FORMS 63-103

HANDBOOK BEGINS HERE

.1 This section lists and defines those forms which are used in the Food Stamp Program and referenced in regulations. Forms which are recommended for use, but are not required, are included as Handbook.

.11 Forms are listed alphabetically by the alpha form designation and number.

.12 The revision date of the form currently in use is specified for each form.

.13 The alpha form designations mean the following:

a. "CA" means Children's Assistance.

b. "DFA" means Division of Financial Administration.

c. "FNS" means Food and Nutrition Service.

d. "FS" means Food Stamps.

e. "I" or "INS" means Immigration and Naturalization Services.

f. "JA" means joint application.

g. "MC" means Medi-Cal.

h. "NA" means Notice of Action.

i. "SAWS" means Statewide Automated Welfare System.

j. "SSA" means Social Security Administration.

.14 For further information regarding Food Stamp forms and form instructions, see Handbook Section 63-1200.

HANDBOOK ENDS HERE

.2 Forms Listing

a. Reserved

b. Reserved

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-94-02 Effective 2/1/94

Page 69.1

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

c. (1) Section 63-103.2c.(1)(MR) shall become inoperative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) CA 7 (rev. 1/93) - Monthly Eligibility Report

The CA 7 is used to report information on a monthly basis by monthly reporting households, to determine the household's continuing eligibility and level of benefits.

(2) CA 8 (rev. 2/84) - Statement of Facts for Additional Persons

The CA 8 is used to collect information necessary to determine the household's eligibility when adding a person.

d. (1) DFA 256 (rev. 11/90) - Participation and Coupon Issuance Report - Food Stamp Program

The DFA 256 is used to collect CWD participation and coupon issuance data.

(2) DFA 285-A1 (rev. 7/90) - Application for Food Stamps - Part (1)

The DFA 285-A1 is completed by applicants and is used to identify households entitled to expedited service.

(3) DFA 285-A2 (rev. 12/04) - Application for Food Stamps - Part (2)

The DFA 285-A2 is completed by applicants and is used to collect the information necessary to determine an applicant's eligibility and benefit level.

(4) Section 63-103.2d.(4)(MR) shall become inoperative and Section 63-103.2d.(4)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) DFA 285-A3 (rev. 4/93) - Important Facts for Food Stamp Applicants

The DFA 285-A3 is used to inform food stamp applicants of their rights and responsibilities and to certify that applicants understand those rights and responsibilities and the penalties for noncompliance.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-02 Effective 7/1/05

Page 69.2

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(QR) DFA 285-A3 QR (rev. 12/03) - Your Right and Responsibilities.

The DFA 285-A3 QR is a required form, no substitutes permitted. The form is used to inform households applying only for food stamp benefits of their rights and responsibilities and to certify that applicants understand those rights and responsibilities and the penalties for noncompliance.

(5) DFA 286 (rev. 4/79) - Household Issuance Record

The DFA 286 is used by CWDs which operate a manual household issuance record card system to record benefit authorizations and transactions.

(6) DFA 287 (rev. 4/80) - Food Stamp Program Identification (ID) Card

The Identification "ID Card" is used to identify the bearer as eligible to receive and use food coupons.

(7) DFA 289 (rev. 4/79) - Food Stamp Program Receptionist's Daily Tally Sheet

The DFA 289 is used to record the daily issuance transactions for each cashier.

(8) DFA 293 (rev. 4/79) - Cashier's Daily Report

The DFA 293 is used to report the daily transaction activity for each cashier.

(9) DFA 296 (rev. 10/88) - Food Stamp Program Monthly Caseload Movement Statistical Report

The DFA 296 is used to report data on monthly CWD application processing activities.

(10) DFA 296 X (rev. 12/88) - Food Stamp Program Expedited Service Quarterly Statistical Report

The DFA 296 X is used to report quarterly data on the CWD's disposition of expedited service requests.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.3

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(11) DFA 300 (rev. 1/80) - Food Stamps Mail Issuance Log

The DFA 300 is used to record mail issuance requests/transactions.

(12) DFA 303 (rev. 10/90) - Replacement Affidavit/Authorization

The DFA 303 is used to document household replacement requests.

(13) DFA 358 (rev. 10/88) - Food Stamp Program Participants by Ethnic Group

The DFA 358 is used to report data on Food Stamp recipients by ethnic group.

HANDBOOK BEGINS HERE

(14) Section 63-103.2d.(14)(MR) shall become inoperative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) DFA 377.1 (rev.3/02) - Notice of Approval

The DFA 377.1 is the recommended CDSS developed form used to inform a household that its application for participation in the Food Stamp Program has been approved.

(15) DFA 377.1A (rev. 3/02) - Notice of Denial or Pending Status

The DFA 377.1A is the recommended CDSS developed form used to inform a household that their application for participation in the Food Stamp Program has been denied after the applicant’s first missed interview. The form is also used for other purposes, such as denying a household due to failure to provide required verification needed to determine eligibility or to notify the applicant of the pending status of their application.

(16) Section 63-103.2d.(16)(MR) shall become inoperative and Section 63-103.2d.(16)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

HANDBOOK CONTINUES

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.4

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

HANDBOOK CONTINUES

(MR) DFA 377.2 (rev. 12/83) - Food Stamp Notice of Expiration of Certification

The DFA 377.2 is the recommended CDSS developed form used to inform a household that their certification period will expire soon or be shortened.

(17) Section 63-103.2d.(17)(MR) shall become inoperative and Section 63-103.2d.(17)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) DFA 377.4 (rev. 12/83) - Food Stamp Notice of Change

The DFA 377.4 is the recommended CDSS developed form used to notify a household of any change in eligibility status or benefit level during the certification period.

(QR) DFA 377.4 QR (rev. 1/04) - Food Stamp Notice of Change for Change Reporting Household

The DFA 377.4 QR is a required form, but substitutes are permitted if CWD obtains prior approval. The form is used to inform change reporting households of changes, and termination of benefits.

HANDBOOK ENDS HERE

(18) Section 63-103.2d.(18)(MR) shall become inoperative and Section 63-103.2d.(18)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) DFA 377.5 (rev. 8/90) - Food Stamp Household Change Report

The DFA 377.5 is used to report information on changes in household circumstances by households not subject to monthly reporting requirements.

(QR) DFA 377.5 (rev. 4/04) – Food Stamp Household Change Report

The DFA 377.5 is used to report information on changes in household circumstances by households not subject to QR requirements.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.5

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

HANDBOOK BEGINS HERE

(19) DFA 377.7A (rev. 8/88) - Notice of Administrative Disqualification

The DFA 377.7A is the recommended CDSS developed form used to notify a household of their disqualification based on an Administrative Disqualification Hearing decision.

(20) DFA 377.7B (rev. 9/93) - Food Stamp Repayment Notice For Inadvertent Household Errors Only

The DFA 377.7B is the recommended CDSS developed form used to initiate collection action against a household or the sponsor of an alien household for an Inadvertent Household Error.

(21) DFA 377.7D (rev. 9/93) - Food Stamp Repayment Notice for Administrative Errors Only

The DFA 377.7D is the recommended CDSS developed form used to initiate collection action against a household or the sponsor of an alien household for an Administrative Error.

(22) DFA 377.7F (rev. 10/93) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only

The DFA 377.7F is the recommended CDSS developed form used to initiate collection action against a household or the sponsor of an alien household for an Intentional Program Violation.

HANDBOOK ENDS HERE

(23) DFA 377.7C (rev. 9/93) - Food Stamp Repayment Agreement for Inadvertent Household Errors Only

The DFA 377.7C is used to specify the terms under which a household has agreed to repay an outstanding claim determination on an Inadvertent Household Error.

(24) DFA 377.7E (rev. 4/93) - Food Stamp Repayment Agreement for Administrative Errors Only

The 377.7E is used to specify the terms under which a household has agreed to repay an outstanding claim determination for an Administrative Error.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.6

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(25) DFA 377.7G (rev. 10/93) - Food Stamp Repayment Agreement for an Intentional Program Violation (IPV) Only

The DFA 377.7G is used to specify the terms under which a household has agreed to repay an outstanding claim determination for an Intentional Program Violation.

HANDBOOK BEGINS HERE

(26) DFA 377.9 (rev. 7/90) - Notice of Back Food Stamp Benefits

The DFA 377.9 is the recommended CDSS developed form used to notify a household of their entitlement to a restoration of lost benefits.

(27) DFA 377.10 (rev. 7/89) - Food Stamp Notice of Disqualification

The DFA 377.10 is the recommended CDSS developed form used to notify a household of its disqualification from the Food Stamp Program for noncompliance with work registration requirements.

HANDBOOK ENDS HERE

(28) DFA 385 (rev. 11/87) - Application for Emergency Food Stamp Assistance

The DFA 385 is used as the application in disasters.

(29) DFA 386 (rev. 3/02) – Notice of Missed Interview

The DFA 386 is the recommended CDSS-developed form used to notify the household that it missed its first scheduled interview and that the household is responsible for rescheduling the missed interview within 30 days of the application date. If the household does not reschedule the interview within the 30 days, the DFA 377.1 is sent to the applicant on the 30th day after the application date to deny the application.

(30) DFA 387 (rev. 3/02) – Request for Information

The DFA 387 is the recommended CDSS-developed form used to notify the household, prior to the CWD taking any adverse action, of verification and clarifications it must provide within 10 days of the request to the CWD. If the household does not respond to the request for information, the food stamp case can be terminated.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.7

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(31) DFA 478 (rev. 6/90) - Disqualification Consent Agreement

The DFA 478 is used in cases of deferred adjudication. Accused individual(s) consent to an appropriate disqualification period with benefit reduction and acknowledge liability for payment of any resulting claim.

(32) DFA 479 (rev. 5/89) - Administrative Disqualification Hearing Waiver

The DFA 479 is an agreement wherein an accused individual(s) waives the right to an Administrative Disqualification Hearing (resulting in an appropriate disqualification period with benefit reduction) and acknowledges liability for payment of any resulting claim.

(33) DFA 842 (rev. 2/87) - Claim Determination Worksheet

The DFA 842 is used to document claim determination computations.

e. Reserved

f. (1) FNS-33 (rev. 4/78) - File Update - Food Coupon Shipping Point

The FNS-33 is used to report changes in bulk storage reporting and coupon shipment receiving points.

(2) FNS-46 (rev. 8/89) - Issuance Reconciliation Report

The FNS-46 is used to report the results of monthly reconciliation activities.

(3) FNS-135 (rev. 7/89) - Affidavit of Return or Exchange of Food Coupons

The FNS-135 is used to document the return or exchange of food coupons.

(4) FNS-209 (rev. 6/86) - Status of Claims Against Households

The FNS-209 is used to report information on CWD claim determination and collection activities.

(5) FNS-250 (rev. 10/78) - Food Coupon Accountability Report

The FNS-250 is used to report data on coupon inventories.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.8

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(6) FNS-254 (rev. 1/82) - Food Stamp Program Authorization/Retailer

The FNS-254 is used to authorize a group living arrangement as a retail food store.

(7) FNS-259 (rev. 5/83) - Food Stamp Mail Issuance Report

The FNS-259 is used to report data on mail issuance activities.

(8) FNS-260 (rev. 1/82) - Requisition for Food Coupon Books

The FNS-260 is used to order coupons.

(9) FNS-261 (rev. 11/78) - Advice of Shipment

The FNS-261 is used by FNS to notify CWDs of the shipment of coupons.

(10) FNS-292 (rev. 8/77) - Report of Coupon Issuance and Commodity Distribution for Disaster Relief

The FNS-292 is used to report the total number of persons certified for emergency coupon allotments and the total number of such allotments.

(11) FNS-300 (rev. 2/90) - Advice of Transfer

The FNS-300 is used to report coupon transfers.

(12) FNS-471 (rev. 4/86) - Coupon Account and Destruction Report

The FNS-471 is used to report the destruction of food coupons.

(13) FS 8 (rev. 4/90) - Important Information About Required Verifications in the Food Stamp Program

The FS 8 is used to provide applicant/recipient households with information on verification requirements in the Food Stamp Program.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.9

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(14) Section 63-103.2f.(14)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(QR) FS 22 QR (rev. 12/04) - Applying for Food Stamp Benefits

An FS 22 QR is a required form, but substitutes are permitted if the CWD obtains prior approval. The form is used to reflect the change to QR for most food stamp households. This form is used for all NAFS households.

(15) Section 63-103.2f.(15)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(QR) FS 23 QR (rev. 3/05) - How to Report Household Changes

An FS 23 QR is a required form, but substitutes are permitted if the CWD obtains prior approval. The FS 23 QR informs about reporting requirements for the Food Stamp Program, which include reporting changes on the QR 7, mandatory mid-quarter reports and voluntary mid-quarter reports.

(16) FS 26 (3/05) – Food Stamp Program Qualifying Drug Felon Addendum

An FS 26 is a required form, no substitutes are permitted. The FS 26 is provided to the household for completion to determine the food stamp eligibility of the drug felon. The FS 26 is used when adding a household member not included on the DFA 285A2, or when additional information is needed on a drug related felony conviction.

g. Reserved

h. Reserved

i. (1) INS I-688 (any rev. date acceptable) - Temporary Resident Card; INS I-688A - Employment Authorization Card; and INS I-688B - Employment Authorization Document.

The INS I-688, INS I-688A, and INS I-688B are used for the verification of alien status as specified in Section 63-300.51(b)(3)(A).

(2) INS G-639 (rev. 1/88) - Freedom of Information/Privacy Act Request

The INS G-639 is used for the verification of alien status.

(3) INS I-94 (any rev. date acceptable) - Arrival-Departure Record

The INS I-94 is used to reflect short-term employment authorization in special circumstances.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-06-01 Effective 2/10/06

Page 69.10

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(4) INS I-179 (rev. 1/73) - U.S. Citizen Identification Card

The INS I-179 is an identification card used to identify resident citizens in the United States.

(5) INS I-551 (any rev. date acceptable) - Resident Alien Card

The INS I-551 is used to verify alien status.

j. (1) BC JA 2 CA 2/DFA 285-A2 (rev. 11/92) - Statement of Facts Cash Aid and Food Stamps

The BC JA 2 CA 2/DFA 285-A2 is completed by applicants and is used to collect the information necessary to determine an applicant's eligibility and benefit level. This form is comparable to DFA 285-A2.

k. Reserved

l. Reserved

m. (1) MC 177-SA-M (rev. 7/89) - Record of Health Cost - Share of Cost

The MC 177-SA-M is used to verify a Medi-Cal recipient's health care costs.

HANDBOOK BEGINS HERE

(2) MC 194 (rev. 9/82) - Social Security Administration Referral Notice

The MC 194 is a recommended form used to verify that an application for a Social Security Number has been completed.

n. (1) Section 63-103.2n.(1)(MR) shall become inoperative and Section 63-103.2n.(1)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

HANDBOOK CONTINUES

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.11

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

HANDBOOK CONTINUES

(MR) NA 960X (rev. 6/93) - Notice of Action/CA 7 not Received

The NA 960X is the recommended CDSS developed form used to notify monthly reporting households that a CA 7 has not been received and that benefits may be affected as a result.

(QR) NA 960X QR (rev. 4/04) - Notice of Action/QR 7 not Received

The NA 960X QR is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. The form is used to notify QR households that a QR 7 has not been received and that benefits may be affected as result.

(2) Section 63-103n.(2)(MR) shall become inoperative and Section 63-103n.(2)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) NA 960Y (rev. 8/93) - Notice of Action/CA 7 Incomplete -Discontinuance Reminder

The NA 960Y is the recommended CDSS developed form used to notify monthly reporting households that a CA 7 is incomplete and that benefits may be affected as a result.

(QR) NA 960Y QR (rev. 4/04) - Notice of Action/QR 7 Incomplete-Discontinuance Reminder

The NA 960Y QR is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. The form is used to notify QR households that a QR 7 is incomplete and that benefits may be affected as a result.

HANDBOOK ENDS HERE

o. Reserved

p. Reserved

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-04-07 Effective 7/1/04

Page 69.12

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

q. (1) Sections 63-103.2q.(1)(QR) through (12)(QR)shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(QR) (2) QR 2 (rev. 4/03) - Reporting Changes for Your Cash Aid Assistance Unit and Food Stamp Household

QR 2 is a CDSS-recommended form, and may be modified or substituted without prior approval. The form is used to inform the recipient of their income reporting threshold (IRT) and reporting responsibilities. The QR 2 is sent to the client on a quarterly basis and is used to satisfy the requirement in Welfare and Institutions Code Sections 11265 and 18910 to inform clients of their IRT at least once per quarter. The form also includes information for food stamp households regarding ABAWD reporting and mid-quarter reporting.

(QR) (3) QR 3 (rev. 4/03) - Mid-Quarter Status Report

QR 3 is a CDSS-recommended form, and may be modified or substituted without prior approval. This form is used for CalWORKs and Food Stamp Program households that choose to report mandatory and/or voluntary mid-quarter changes in writing. Clients are not mandated to use this form, and counties must accept verbal or written mid-quarter reports that are submitted in a manner other than on the QR 3.

(QR) (4) QR 7 (rev. 4/03) - Quarterly Eligibility/Status Report

QR 7 is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. This form is used by the household to report income for the Data Month changes since the last Data Month and expected changes over the next three months. This form includes an addendum listing examples of income, expenses, and the penalties for fraud. The QR 7 and the addendum (both together are considered one form) must be sent to the recipient at the end of their QR Data Month. The QR 7's certification section has a statement that the client has received the addendum and a place where the recipient will attest to its receipt. The addendum is not required to be returned with the QR 7, which will be considered late if not received by the 11th day of the QR Submit Month.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.13

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(QR) (5) QR 7A (rev. 4/03) - How to fill out your QR 7

QR 7A is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. This form instructs recipients on how to fill out the QR 7. The QR 7A must be given to applicants at the time of application, and to recipients at each annual recertification/redetermination. This form must also be made available any time a client requests it.

(QR) (6) QR 22 (rev. 9/03) - Sponsor's Statement of Facts Income/Resources

The QR 22 is a required form, but substitutes are permitted if CWD obtains prior approval. It is used to collect necessary information about a noncitizen's sponsor in order to determine eligibility for the noncitizen.

(QR) (7) QR 72 (rev. 5/04) - Sponsor's Quarterly Income and Resources Report.

The QR 72 is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. This form must be sent to sponsored noncitizens with the QR 7 each quarter.

(QR) (8) QR 285-B (rev. 2/04) - Food Stamp Budget Worksheet.

The QR 285-B is a CDSS-recommended form, and may be modified or substituted without prior approval. This form is used to determine food stamp benefits amounts, and to reaverage benefit amounts after a mid-quarter report is made by a recipient. The QR 285B is used for food stamp households subject to QR and change reporting, and for mid-quarter changes.

(QR) (9) QR 377.1 (rev. 4/04) - Notice of Approval

The QR 377.1 is a CDSS-required form, and no substitutes are permitted. This form is used to inform households of their approval for food stamp benefits and their certification period.

(QR) (10) QR 377.2 (rev. 4/04) - Food Stamp Notice of Expiration of Certification

The QR 377.2 is a CDSS-required form but substitutes are permitted. This form is used to inform change reporting households that their certification period will expire.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.14

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-103 (Cont.)

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(QR) (11) QR 377.4 (rev. 1/04) - Food Stamp Notice of Change For Quarterly Reporting Household

The QR 377.4 is a CDSS-required form, but substitutes are permitted if CWD obtains prior approval. This form is used to inform change reporting households of changes and termination of benefits.

(QR) (12) QR 377.5 (rev. 2/04) - Food Stamp Household Mid-Quarter Status Report

The QR 377.5 is a recommended form and is used to report mandatory and voluntary mid-quarter changes in a QR household.

r. Reserved

s. (1) SAWS 1 CA1/DFA 285-A1 (rev. 9/90) - Application for Cash Aid, Food Stamps, and/or Medical Assistance

The SAWS 1 CA1/DFA 285-A1 is completed by applicants and is used to identify households entitled to expedited service. This form is comparable to the DFA 285-A1.

(2) Section 63-103.2s.(2)(MR) shall become inoperative and Section 63-103.2s.(2)(QR) shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(MR) SAWS 2A CA2/DFA 285-A2/MC210 (rev. 5/92) - Important Information for Applicants and Recipients for Cash Aid, Food Stamps, and Medical Assistance

The SAWS 2A CA 2/DFA 285-A2/MC210 is used to inform applicants for cash aid, food stamps, and medical assistance of important information, including their rights and responsibilities.

(QR) SAWS 2A QR (rev. 8/03) - Rights, Responsibilities and Other Important Information

SAWS 2A QR is a CDSS-required form, and no substitutes are permitted. The form is used to inform applicants for cash aid, food stamps, and medical assistance of important information, including their rights and responsibilities.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-03 Effective 8/5/05

Page 69.15

FOOD STAMP REGULATIONS

63-103 (Cont.) GENERAL PROVISIONS Regulations

63-103 DEFINITIONS--FORMS 63-103

(Continued)

(3) SSA-2853-OP3 (rev. 6/89) - Information About When You Will Receive Your Baby's Social Security Card

The SSA-2853-OP3 is used to verify that an application for a Social Security Number has been filed by a hospital official for a newborn.

(4) SSA-5028 (any rev. date acceptable) - Receipt of Application for a Social Security Number

The SSA-5028 is used to verify that an application for a Social Security Number has been completed.

t. (1) Section 63-102.2t.(1)(QR)shall become operative in a county on the date QR/PB becomes effective in that county, pursuant to the Director's QR/PB Declaration.

(QR) TEMP QR 1 (rev. 8/03) - New Reporting Requirements for CalWORKs and Food Stamp Recipients

TEMP QR 1 is a CDSS-required form, and no substitutes are permitted. The form serves as an informing notice sent to recipients on a monthly basis for a period of three months before, and three months after, implementation of QR. The TEMP QR 1 should also be provided to applicants who apply for benefits during this phase. The TEMP QR 1 explains the change from monthly reporting to QR.

u. Reserved

v. Reserved

w. Reserved

x. Reserved

y. Reserved

z. Reserved

NOTE: Authority cited: Sections 10554, 11265.1, .2, and .3, 18901.3, 18904, and 18910, Welfare and Institutions Code. Reference: Sections 10554, 11265.1, .2, and .3, 18901.3, 18904, and 18910, Welfare and Institutions Code; 7 CFR 273.2(b)(ii), (e) and (f); U.S.D.A. Food and Consumer Services Administrative Notice No. 94-22, dated January 7, 1994, Federal Register, Vol. 66, No. 229, dated November 28, 2001; and Food and Nutrition Service Quarterly Reporting/Prospective Budgeting waiver approval dated April 1, 2003.

CALIFORNIA-DSS-MANUAL-FS

MANUAL LETTER NO. FS-05-02 Effective 7/1/05

Page 69.16

FOOD STAMP REGULATIONS

Regulations GENERAL PROVISIONS 63-104 (Cont.)