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FOOD STAMP HANDBOOK ~ Handbook _. ___FORMS AND INSTRUCTIONS _ _ 63-1230 (Cont.} 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DFA 377.9 (3/81)

(COUNTY STAMP)

NOTICE OF RESTORATION OF LOST FOOD STAMP BENEFITS AND RIGHT TO REQUEST A STATE HEARING

i “T case Name:

Case No? Worker No: District: Date:

L —!

2 A determination has been made that you are eligible for a restoration of fast tood stamp benefits in the amount of

See fOF the Month(s) of dua-to:

im There is an unpaid claim against your household in the amount of $ « Your entitlement to the fost benefits described above has been offset by this claim and your total entitlement has been reduced to $ . The unpaid balance of the claim Is $. :

This entitlement will be issued to you in ane jump sum, unless installments are requested by you. Please contact your worker if you would like the amount due you paid in instaliments.

This action ls required by the following laws and/or Food Stamp Manual Sections: 63802

(f you have any questions, please contact me. ELIGIBILITY WORKER . TELEPHONE HUMBER DATE

ff you disagree with this computation, you have the right to request a stale hearing with the Stale Department of Social Services. See reverse for your state hearing rights.

Dia 177 9 9/806 Hogu tert

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CALIFORNIA-DSS-MANUAL-SS issue 2232 Issued 8/14/81