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“FOOD STAMP HANDBOOK Handbook _ ~--+--—.-FORMS AND INSTRUCTIONS _ 63-1230 (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 compiaint should you feel you have been discriminated against.

@ To discuss any action fegarding your case with the County Welfare Department any time you are dissatisfied. © fo request a state hearing within 90 days if you are dissatisfied with any action taken by the County Welfare Oepartment. e

To file a complaint or request a stata hearing by writing to the Department of Social Services, 744 P Street, Sscramento, CA 95814 or by calling tall free 1-800-952-5253, The toll free number for the deaf {TDD) is 1-BO0-962-8349,

YOUR RESPONSIBILITIES AS AN APPLICANT OR RECIPIENT:

@ = To provide documents te confirm the information on this apptication. if documents are not availabie, to give the name of a person ar organization the food stamp office may contact to obtain the necessary verification,

@ To cooperate fully with county, state and federal personnel in a quality control review.

Ol MONTHLY REPORTING HOUSEHOLOS © To file 8 compiete monthiy report (CA 7} by the 5th day of the month.

@ To provide any additional information or verificatian 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 8s, but no later than 10 days, from the time you jearn of any of the following changes: . The gross monthly income raceived by your household increases or decreases by more than $25, The source of any income received by you or any member of your household changes. You change your addrass, There are any changes in housing or utility costs because you move. Aayone moves in or out of your home. The property owned by you or any member of your household changes; for example, you

acquire & licensed vehicie, of the total of your household's stocks, bonds, or other money reaches or exceeds 81500,

* There is an increase or decrease of more than 625 in medical expenses for a household member who is disabled or age 60 or older.

® To report any changes to the County Welfare Department by telephone, by mail or by coming into the food stamp office,

@ = To meat the reporting responsibilities for the AFDC or Refugee/Entrant Cash Aid Programs if you receive cash aid as well as food stamps,

# youhave any doubt about Needing te report any change, contact your worker, If you fail to report a change and because of this you receive food stamp benefits you sre not entitied to, you will have to rapay them. PENALTY WARNING: IF YOUR HOUSEHOLD RECEIVES FOOD STAMPS, IT MUST FOLLOW THE RULES LISTEO BELOW. IF YOU OR ANY MEMBER OF YOUR” HOUSEHOLD BREAKS ANY OF THESE RULES ON PURPOSE YOU MAY BE PERMANENTLY DISQUALIFIED FROM THE FOOD STAMP PROGRAM. IN ADDITION, YOU MAY BE FINED UP TO 610,000 AND/OR IMPRISONED FOR UP TO 5 YEARS,

« Do not give faise information or withhold information to get or continue to gat food stamps.

« Do not trade of sal! food stamps or ATPs,

+ Do not aiter ATPs to get food stamps you are not entitled to receive,

« Do not use foad stamps to buy ineligible items such as alcoholic drinks and tobacco,

e Do not use someone eise’s food stamps or ATPs for your household.

YOUR CERTIFICATION

(certify that ! understand the questions on the application and that | have read the above (or had it read to me), and that lunderstand my responsibilities. | understand that the information that have provided will be varifiad by local, state and federal parsonnel. jalso understand that if any of this information is found to be incorrect, | may be disqualifiad from the Program and subject to criminal prosecution for krrowingly providing faise information. | further understand the penaities for breaking any of the rules listed above.

SIGNATURE (HEAD GF HOUSEHOLD, HOUSEHOLD MEMBER OR AUTHOMIEED REPABEENTATIVE! DATE

WITNESS, iF VOU BIGNED WiTH AN GATE

t certify that | have informed the appticant/recipient af the above responsibilities and of the possibilities of criminal penalties for intentianally making {aise statements or failing to raport information which affects food stamp eligibility.

TIORATORE GF WIEBE WORKER GATE Koay WERTION REVIEWED WaT ELENA GR ALANGREED RERRESETATNN id Page 5 of 5 CALIFORNIA-DSS-MANUAL-SS issue 644 Issued 2/15/84

(MANUAL LETTER NO. 84-13) (2 3