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Handbook __ FORMS AND INSTRUCTIONS 63-1230 (Cont.}

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

DFA 377.4 (12/83)

: (Instructions Revised 4/6/84) Form Instructions

(for the Eligibility Worker} FOOD STAMP NOTICE OF CHANGE

Purpose:

The DFA 377.4 is used by the Eligibility Worker to notify a household of any of the following actions:

- Changes in food stamp benefits during the certification period;

- One-month suspension of benefits;

~ Termination of program participation;

- Possible reduction or termination of benefits because a complete CA 7 is missing verification and/or contains questionable information.

The back of the DFA 377.4 explains the household's right to request a state hearing and provides instructions on how to appeal the action. The back also provides information needed by the

household to receive continued benefits pending a hearing if benefits are being reduced, terminated or suspended.

NOTE: If the CA 7 is incomplete for any program in which the household is participating, the NA 960Y, CA 7 Incomplete--Discontinuance/Reminder, must be used instead of the DFA 377.4 as the timely reminder notice.

Preparation:

Complete an original and two copies of the DFA 377.4, entering the following identifying information.

~ Head of househoid’s name and mailing address - Case Name

- Case Number

- District (if applicable)

- Worker

~ Phone Number

~ Date of Notice

Complete the action portion of the notice by checking the heading box for the Change, Suspension, Termination, or Proposed Change section, and entering all other required information.

When benefits are changed, suspended or terminated as a result of a reported change, and/or the disallowance of a deduction, the reason for the action must include the reported change and/or

the disallowed deduction. For example: ‘’... your food stamp benefits are changed... because your gross monthly income increased from $250 to $350 and your dependent care expenses were not allowed.”; or, “.., your household size decreased from 4 to 2.”

CALIFORNIA-DSS-MANUAL-SS Rev. 1389 repiaces Effective 2/15/84