Page 101

Handbook _ FORMS AND INSTRUCTIONS 63-1230 (Cont.)

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 377.7A (3/84)

Form instructions (for CWD)

FOOD STAMP NOTICE OF ADMINISTRATIVE DISQUALIFICATION

Purpose:

The DFA 377.7A is used by the county to notify an individual that he/she has been found guilty of committing an intentional program violation, that he/she will be disqualified for a certain period

of time, and provides information to the rest of the household concerning its eligibility for food stamps during the disqualification period.

The back of the DFA 377.7A explains the rest of the household's right to request a state hearing if it disagrees with the amount of food stamp benefits it will receive during the disqualification

period. If the household requests a hearing, benefits will not continue until the hearing at the level prior to this notice.

NOTE: If the household has reported a change in circumstances which also affects its benefit level, this change must be computed separately from the disqualification. A Notice of Change (DFA 377.4} showing the change in circumstances must be attached to the DFA 377.7A when: (1) the change in benefits due to the change in circumstances and the change in benefits due to the disqualification are effective the same date, and (2) sufficent time exists for the Notice of Change to be issued on a timely basis. The Notice of Administrative

Disqualification must show only the benefit level resulting from excluding the disqualified individual.

Preparation:

The DFA 377.7A should be completed and sent to the individual found guilty of committing an intentional program violation. This notice need not be issued 10 days before the effective date of the disqualification but must be sent in sufficient time for the individual to receive the notice before

the disqualification period begins. Complete an original and two copies of the DFA 377.7A entering the following identifying information:

- Individual’s name and mailing address - Case name

- Case number

- Worker number

- District (if applicable}

- Date of Notice

Disqualification Decision

Check the first box if the individual was found guilty of committing an intentional program violation at an administrative disqualification hearing, Enter the date of the hearing.

Rev. 1390d replaces .

Page 101

Official source

Handbook _ FORMS AND INSTRUCTIONS 63-1230 (Cont.)

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 377.7A (3/84)

Form instructions (for CWD)

FOOD STAMP NOTICE OF ADMINISTRATIVE DISQUALIFICATION

Purpose:

The DFA 377.7A is used by the county to notify an individual that he/she has been found guilty of committing an intentional program violation, that he/she will be disqualified for a certain period

of time, and provides information to the rest of the household concerning its eligibility for food stamps during the disqualification period.

The back of the DFA 377.7A explains the rest of the household's right to request a state hearing if it disagrees with the amount of food stamp benefits it will receive during the disqualification

period. If the household requests a hearing, benefits will not continue until the hearing at the level prior to this notice.

Disqualification must show only the benefit level resulting from excluding the disqualified individual.

Preparation:

the disqualification period begins. Complete an original and two copies of the DFA 377.7A entering the following identifying information:

- Individual’s name and mailing address - Case name

- Case number

- Worker number

- District (if applicable}

- Date of Notice

Disqualification Decision

Check the first box if the individual was found guilty of committing an intentional program violation at an administrative disqualification hearing, Enter the date of the hearing.

Rev. 1390d replaces .