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FOOD STAMP HANDBOOK Handbook FORMS AWD INSTRUCTIONS 63-1230 (Cont.)

63~1230 STATE FORMS AND INSTRUCTIONS (Continued) 63-1230

DFA 377.7C (3/84)

Form Instructions (for CWD)

FOOD STAMP REPAYMENT AGREEMENT ’ Purpose: The DFA 377.7C is used by the

with an individual who received i t to the individual al,

ure a written repayment agreement food stamps. This agreement ice, DFA 377.7B ).

NOTE: The CWD should attempt to contact the individual to discuss the terms of repayment prior to sending the first Food Stamp Repayment Notice and Agreement.

Preparation:

Complete an original and three copies of the DFA 377.7C. Additional copies may

be required by the county's internal system, Enter the following identifying information:

- Case number

- Worker

- Name of individual against whom collection action is initiated - Case name

- Address

Terms and Conditions

a Check the first box for a claim based on an inadvertent household error; the second box for an intentional program violation; or, the third box for an inistrative error.

a

Check the box in item 4 if the court ordered the terms of repayment of an intentional program violation claim. Complete the appropriate sections of the

Agreement to reflect the court-ordered terms before sending the Agreement to the individual.

Enter the epfprép

CALIFORNIA-SDSS-MANUAL—FS MANUAL LETTER NO. PS-90-01 Effective 2/1/90 Rev. 984 replaces Rev. 1390m 7 ()