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FOOD STAMP HANDBOOK Handbook FORMS AND INSTRUCTIONS 63-1230 (Cont,)

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

DFA 377.78 (3/84)

State of California ~ Health und Welfare Agency Department of Saciat Services

FOOD STAMP REPAYMENT NOTICE

Cave Name: Case Number: District: Worker: Phone:

Date of Notice:

EXTRA FOOD STAMPS WERE ISSUED

BD After reviewing your food stamp file, we found you received more food stamps than you were entitled to receive,

CO) After reviewing the food stamp file for received more food stamps than he/she was entitled to receive.

» whom you sponsor, we found he/she

The extra food stamps were issued because:

THIS IS WHAT YOU OWE

$s in extra food stamps were issued for the period

This amount was reduced by $ because we owed the household benefits from past months or we received repayment of part of the amount owed. You now owe $

Ef you believe that the amount you owe is wrong, you may request a state hearing, unless you already had a hearing on the amount you owe,

THIS IS WHAT YOU MUST DO

DB You must Fepay the extra food stamp benefits. Please complete the attached Repayment Agreement, sign and return it to the County Welfare Department.

Oar you do not return an acceptable Repayment Agreement within 30 days after the date of this notice, your househoid’s food stamp benefits will be reduced to $ effective

YOU DID NOT REPAY AS AGREED

you must contact us to explain why you did not repay food stamp benefits as you agreed. If you can no longer afford to pay the amount due as agreed, you may ask to renegotiate your agreement.

0 if we do not hear from you within 10 days of the date of this notice, your household’s food stamp benefits will be reduced to $ effective

The above action is required by the following Food Stamp Manual Section(s):

, Name Phone Number Hf you have any questions, please contact me:

You huve the right to request a state hearing if you believe this action is wrong. See the back of this notice for a state hearing request.

DEA MIT IB LN Rat Required Firm Ne Subseitetes Permitted

Rev. 13909 replaces . CALIFORNIA-DSS-MANUAL-SS Issue 2225. Effective 2/15/84