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FOOD STAMP HANDBOOK

Handbook sss FORMS AND INSTRUCTIONS 63-1230 (Cont,)

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

63-1230

DFA 377.74 (3/84)

Stme of California - Heaith and Welfare Agency Department of Social Serviees

FOOD STAMP NOTICE OF ADMINISTRATIVE DISQUALIFICATION

Case Name: x Case Number: District: Worker: Phone; Date of Notice:

DISQUALIFICATION DECISION

© You were found guilty of committing an intentional program violation at a hearing held on See the State Department of Social Services hearing decision you received earlier for a complete explanation. This decision does not prevent the state or federal government from prosecuting you in court.

1 You were found guilty of committing an intentional program violation by a court of law on See the court decision for a complete explanation.

DISQUALIFICATION PENALTY As a result of the above decision, you have been disqualified from the Food Stamp Program,

O Since you are currently otherwise eligible for the Program, you will not receive any food stamps for TRONS, C£PCCtiVE sen remnenennnnnunnmemnmim en

© since you are not currently otherwise eligible for the Program, when you reapply and are determined eligible, you will not receive any food stamps fOr .uenmmememmer Months.

EZ You have been permanently disqualified from the Program and will never receive food stamps again.

NOTICE TO THE OTHER MEMBERS OF YOUR HOUSEHOLD

Because of the above decision, your food stamp file has been reviewed to see if you will receive food stamps while is disqualified.

0 Your benefits will change from $ to $ effective

(1 You would have received $ in food stamps, but because you had another change in circumstances A A A : iP ¥ . : you will receive a different amount. See the attached Notice of Change for the amount you will actually receive.

(1 You are fo longer eligible for food stamps as a result of excluding the disqualified individual from your

benefit computation. You may reapply for food stamps at the end of the disqualification period ar if your circumstances change.

o Although your certification period is over, you may be eligible for food stamps. To see if you are eligible, you may call, write or visit the county welfare department and request an application,

IF YOU BELIEVE THAT THE AMOUNT OF FOOD STAMPS YOU WILL RECEIVE IS WRONG, YOU MAY REQUEST A STATE HEARING. A REQUEST FOR A STATE HEARING IS ON THE BACK OF THIS NOTICE.

IF YOU REQUEST A HEARING, YOUR BENEFITS WILL NOT CONTINUE UNTIL THE HEARING AT THE LEVEL PRIOR TO THE DISQUALIFICATION,

The above action(s) is required by the following Food Stamp Manual Section(s}:

. ‘Name Phone Number if you have any questions, please contact me:

See the back of this notice for a hearing request.

DEA RTT IA LY R41 Required Poems « Nu Suhanietes Peroiinted

CALIFORNIA-DSS-MANUAL-SS Rev. 1390b replaces Effective 2/15/84

__. issue 2220