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FOOD STAMP HANDBOOK FORMS AND INSTRUCTIONS

Handbook

_--83-1230 (Cont) | 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 285-A2 (12/83)

IMPORTANT INFORMATION - READ CAREFULLY

YOUR RIGHTS AS AN APPLICANT OR RECIPIENT:

@ = To be served without regard to race, color, national origin, religion, political affiliation, sex, handicap, or age: and to file a complaint should you feel you have been discriminated against,

To discuss any action ragarding your case with the County Welfare Oeparment any time you are dissatisfied. © To request a state hearing within 90 days if you are dissatisfied with any action taken by the County Welfare Department,

@ = To file a comptaint or request a state haaring by writing to the Department of Social Services, 744 P Street, Sacramento, CA 95814 or by calling toll free 1-800-952-5253, The toil frae number for the daaf (TDD) is 1-800-982-8349,

YOUR RESPONSIBILITIES AS AN APPLICANT OR RECIPIENT:

@ = To provide documents to confirm the information on this application, if documents are not available, to give the name of a person or organization the food stamp office may contact to obtain the necessary verification,

® To cooperate fully with county, state and federal personnei in a quality contro! review. 1 MONTHLY REPORTING HOUSEHOLDS @ To file a compiete monthly report (CA 7) by the Sth day of the month.

@ To provide any additional information or verification requested by the County Welfare Department as a result of information you report on the CA 7,

€) NONMONTHLY REPORTING HOUSEHOLDS ® To notify the County Welfare Department as soon as, but no later than 10 days, from the time you learn of any of the following changes: . The gross monthly income recaived by your household increases or decreases by more than $25. The source of any income received by you or any mamber of your household changes. You change your address, There are any changes in housing or utility costs because you move. Anyone moves in or out of your home.

The property owned by you or any member of your household changes; for exampie, you

acquire & licensed vehicie, or the total of your household's stocks, bonds, or other money reaches or exceeds $1500,

* There is an increase or decrease of more than $25 in medical expenses for a household member who is disabled or age 60 or older.

@ Yo report any changes to the County Welfare Department by telephone, by mail or by coming into the food stamp office.

@ . To meet the reporting responsibilities for the AFDC or Refugea/Entrant Cash Aid Programe if you receive cash aid as well as food stamps.

if you have any doubt about needing to report any change, contact your worker. if you fail to report a change and because of this you recaiva food stamp benefits you are not entitled to, you will have to repay them,

PENALTY WARNING: IF YOUR HOUSEHOLD RECEIVES FOOD STAMPS, IT MUST FOLLOW THE RULES LISTED BELOW. IF YOU OR ANY MEMBER OF YOUR HOUSEHOLD BREAKS ANY OF THESE RULES ON PURPOSE YOU MAY 8E PERMANENTLY DISQUALIFIED FROM THE FOOD STAMP PROGRAM. iN ADDITION, YOU MAY BE FINED UP TO $10,000 AND/OR IMPRISONED FOR UP TO 5 YEARS.

*® Do not give falsa information or withhold information to get or continue to get food stamps,

* Do not trade or sei food stamps or ATPs.

« Do not alter ATPs to gat food stamps you are not entitled to receive. « Do not use food stamps to buy ineligible items such as alcohaile drinks and tobacco, « Do not use someone eise’s food stamps or ATPs for your househoid,

YOUR CERTIFICATION :

| certify that { understand the questions on the application and that { have read the above {or had it read to me}, and that | undarstand my responsibilities. | understand that the information that {have Provided will be varified by local, state and faderal personnal, (also understand that If any of this information is found to be incorrect, | may be disqualified from the Program and subject to criminal prosecution for knowingly providing false information. | further understand the penatties for breaking any of the rules fisted above.

SIGNATURE (HEAD OF HOUSEHOLD, HOUSEHOLO MEMBER OF AUTHOREED REPRESENTATIVED ‘DATE,

WITNESS, © YOU SIGNED WITH AN” OATE

{ certify that | have informed the applicant/recipiemt of the sbove responsibilities and of the possibilities of criminal

penalties for intentionally making false statements or failing to report information which affects food stamp eligibillty. BIGNATURE OF INTERVIEWING WoRKFR

‘DATE APPLICATION REVIEWED WITH CLIENT OR AUTHORGED REPRESENTAINE

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CALIFORNIA-DSS-MANUAL-SS_ Rev, 1351 replaces Issue 2173 Effective 2/15/84

(MANUAL LETTER NO. 84-13) (9 3 ¥