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FOOD STAMP HANDBOOK

Handbook FORMS AND INSTRUCTIONS ___ 88-1214 63-1211 ACTIVE STATE FOOD STAMP FORMS (Continued) 63-1211 Form Form and Modification Current Form instruction Policy

Form No. Title Version Designation® Provided Provided DFA 303 Replacement Affidavit/Authorization 1-83 R-SP Yes Yes DFA 332.1 Verification of Faod Stamp ATP Usage 8-73 + No No DFA 377.1 Food Stamp Notice of Action 12-83 R-NS Yes Yes DFA 377.2 Food Stamp Notice of Expiration

of Certification 12-83 R-NS Yes Yes DFA 377.4 Food Stamp Notice of Change 12-83 R-NS Yes Yes DFA 377.5 Food Stamp Household Change

Report. 42-83 R-NS Yes Yes DFA 377.7A Food Stamp Notice of Administrative

Disqualification 3-84 R-NS Yes Yes DFA 377.7B Food Stamp Repayment Notice 3-84 R-NS Yes Yes DFA 377.7C Food Stamp Repayment

Agreement 3-84 R-NS Yes Yes DFA 377.9 Notice of Restoration of Lost

Food Stamp Benefits 3-81 R-SP Yes Yes BFA 385 Application for Emergency Food Stamp

issuance 2-80 + No No DFA 440 Verification of Physical or

Mental incapacity 5-78 + No No DFA 842 Claim Determination Worksheet 6-81 R-SP Yes Yes NA 960X Notice of Action (CA 7 Not

Received — Discontinuance) 4-B4 R-NS Yes Yes NA 960Y Notice of Action (CA 7 Incomplete —

Discontinuance/Reminder) 1-84 R-NS Yes Yes

*Form Designation

R-NS Required Form — No Substitutes

R-SP Required Form — Substitutes Permitted Rec. Recommended Form

+ Designation Pending

CALIFORNIA-DSS-MANUAL-SS Rev. 1343 replaces Issue 2165 Effective 2/15/84

(MANUAL LETTER NO. 84-13) V/4]