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FOOD STAMP HANDBOOK 63-1230 (Cont,)

Handbook __ FORMS AND INSTRUCTIONS

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 . DFA 377.4 (12/83)

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State of Lattorna

Departement ot Soe ae Secu ng Health and Wellare Agency FOOD STAMP NOTICE OF CHANGE ff you have any questions or want more information about this action, please contact your workar, Case Name Case Number : District 3 Worker : Phone : Oste of Notice: O CHANGE IN BENEFITS. Effective + your food stamp benefits are changed from # los ee each month because:

O SUSPENSION. Effective your food stamp benefits are suspended because:

You will not receive any food stamp banatits for . During this period of suspension, you must continue to complete and submit your monthly report (CA 7) 80 we can determina if you will be eligible for benetits the month afier the month oftuspansion. ff youdonct submit a complete CAT during the month of suspension, your food Gtamp participation will be terminated.

Cl TERMINATION, Effective + your food stamp benefits are tarmingted becnuse:

{ Based an the reason your bensfits are lerminated, your household is also disquatified fram participating in the Food Siamp Program until . You may reapply for benefits at the end of this diequalification petod.

QO PROPOSED CHANGE iN BENEFITS. EHective » your food stamp benefits may be leduced or terminaiad because information neaded to determine your continued eligibility or the correct amount of your benefits was not receawed wih your monthly report (CA 7}. We must receive the following information by no later than the first day of next month:

if vertication af sn expense is requasted and you do not provide it, the expanse will not be eflowed when computing meat month's benelits. Also, # you do not provide other fequested information, your benefits may be seduced o¢ lermingied,

Comment:

The above action(s} is required try the following Food Stamp Manual Section(sr

You have the right to request § state hearing H you believe thie action ie wrong, See the beck for a hearing tequect.

DFA 377.4 (12/83) Regusred Form . No Substautas Permated

‘commer a .

CALIFORNIA-DSS-MANUAL-SS Rev. 1387 replaces Effective 2/15/84

ee __ issue 2212 _ a vet erent otneene