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FOOD STAMP HANDBOOK

£3-1230 (Cont) FORMS AND INSTRUCTIONS __ Handbook

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

DFA 377.7A (3/84)

Check the second box if the individual was found guilty of committing an intentional program violation by a court of law. Enter the date of the court decision.

' Disqualification Penalty

Check the appropriate box and enter the specific information concerning the individual's disquali- fication period.

Check the first box if the household is currently otherwise eligible to participate in the Program. Enter the number of months the disqualified individual will not receive food stamp benefits and the effective date of the disqualification.

Check the second box if the household is not currently otherwise eligible to participate in the Program. Enter the number of months the disqualified individual will not receive food stamp benefits when applying and. found eligible in the future because of the disqualification.

Check the third box if the individual has been permanently disqualified.

Notice to the Other Members of Your Household (This section is not completed if the disqualified individual is the only household member.)

Enter the name of the disqualified individual. Check the appropriate box and enter the specific information concerning the household’s benefit level after excluding the disqualified individual.

Check the first box if the rest of the household is still eligible to receive food stamps, and either its benefits for the following month are not affected by a reported change in circumstances, ora

timely Notice of Change has already been provided. Enter the current allotment, the new allot- ment and the effective date of the change.

Check the second box if the househoid has reported a change in circumstances which changes the benefit level it would have received based on the disqualification alone, and a timely Notice

Check the third box if the household is no longer eligible for food stamps as a result of excluding the disqualified individual from the benefit computation.

Check the fourth box if the household's certification period has expired,

Manual Section(s}

Enter the applicable specific manual section(s) for the above action(s).

CALIFORNIA-DSS-MANUAL-SS Rev. 1390e replaces Effective 2/15/84

_ Issue 2223

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