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

DFA 377.9 (3/81)

Form Instructions (for Eligibility Worker)

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

Purpose:

The DFA 377.9 is used by the Eligibility Worker to notify a food stamp household of its eligibility for restoration of lost benefits and, if applicable, of the offsetting of such benefits by unpaid claims.

The backside of the DFA 377.9 explains the household’s right to request a hearing and provides instructions on how to appeal the intended action.

Preparation:

Complete an original and two copies of the DFA 377.9 entering the following identifying information: - Head of household's name and mailing address

- Case name

- Case number

~ Worker number

- District (if applicable)

- Date

Check the first box and enter the following information:

~ The amount of food stamp benefits which the household is eligible to have restored.

- The month(s) for which these benefits were lost.

~ The reason why the benefits were lost and the Food Stamp Manual section governing the restoration.

Check the second box if the househoid has an unpaid claim which offsets all or a portion of the lost benefits to which it is entitled. Enter the following information:

- The amount of the unpaid claim,

- The remaining lost benefit entitlement, if any, after the unpaid claim has been deducted from ‘the original entitlement, or zero if the entire entitlement was offset by the unpaid claim.

CALIFORNIA-DSS-MANUAL-SS Rev. 1391 replaces Issue 2234 Effective 2/15/84