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FOOD STAMP HANDBOOK 63-1230 (Cont.) ELIGIBILITY DETERMINATIONS Handbook

63-1230 STATE FORMS AND INSTRUCTIONS (Continued) 63-1230 DFA 377.7C (3/84) Agreement

Enter the individual's name, the county name, and the amount to be repaid in the spaces provided.

If the CWD was able to contact the individual and establish the terms of repayment, check the appropriate box(es) under the repayment options and enter the agreed-upon amounts and dates.

If the CWD was unable to contact the individual or is unable to establish the terms of repayment, do not enter any information under the repayment options.

Initial Distribution: The original and two c

Stamp Repayment Notice third copy is retained by

individual along with the Food and a return envelope. The f the signed Agreement.

County~Use Section

When the signed Agreement is returned by the individual, determine if the terms are acceptable as specified by regulation. Enter the following information in

- . Name of county official accepting Agreement - Date

- Name of county

- Address where payments should be § - Signature of authorized county off

Final Distribution:

The original collections.

j The second signed copy is filed in the case record and the pended copy is destroyed. Additional copies should be distributed g@ounty needs.

CALIFORNIA-SDSS-MANUAL-FS MANUAL LETTER NO. PS-90-01 Effective 2/1/90 Rev. 985 replaces a Rev. 1390n “] HD