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Handbook FORMS AND INSTRUCTIONS ____ 63-1230 (Cont) 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DFA 377,7C (3/84} Stale of California + Health and Welfure Agency Department of Social Services FOOD STAMP REPAYMENT AGREEMENT Cone Nurser Worker Name [Case Name Address

TERMS AND CONDITIONS

You must repay extra food stamp benefits in one or a combination of the methods described below:

1. Lump Sum Payment — You may repay all or part of the amount owed at one time with cash and/or coupons, including setuming coupons already received.

2. Installments — You may repay all or part of the amount owed in monthly installments with cash and/or coupons,

including returning coupons already received, .

3. Benefit Reduction — If you are currently receiving food stamps, you may repay by having your household's benefits

reduced for all or pant of the amount owed, Repayment by this method will be based on the terms checked below: Gl At teast 10% of your monthly allotment or $10 each month, whichever is greater. At least 20% of your monthly allotment or $10 each month, whichever is greater. Discussion with you about the amount to be reduced, 4, Court-Ordered Repayment The court ordered that you repay as indicated below. These repayment terms cannat be changed by you or by the County. If we have not already contacted you to discuss the terms of this Agreement, or if you have any questions about this form, please contact me: at (phone number)

AGREEMENT 1,

, the undersigned, understand this Agreement is entered into between me and County because extra food stamps in the amount of $ issued. I agree to repay this amount to the County by the method(s) checked below:

1, Lump Sum Payment

wers

a Repay by a lump sum cash payment of § due on Repay by a lump sum coupon payment of $ due on 2. Installments a] Repay by monthly cash payments of $ due on the day of each month beginning through . Oo Repay by monthly coupon payments of $ —___ due on the day of each month beginning through 3. Benefit Reduction o Repay by having my household's benefits reduced by$ —_ seach month, beginning through .

! understand that if my circumstances change, | may ask the County to recansider the terms checked above. | understand that if { cannot reach an agreement with the County, | may ask for a state hearing.

Signed by

on at (Dare)

County, California,

After completing and signing this Agreement, return all copies to the County Welfare Department in the envelope provided. Do not send cash or coupons through the mail with this Agreement. When accepted by the County, a signed copy of this

Agreement will be sent to you. A request for a State Hearing is on the back of the Foad Stamp Repayment Notice sent to you with this Agreement.

COUNTY USE ONLY |

‘The above signed Agreement hax been accepted by on

Titet for

County. Payments should be made at:

iShmature of Authorized County Ofheat)

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Effective 2/15/84