Form CF377.4 CR "Calfresh Notice of Change for Change Reporting Households" - California

What Is Form CF377.4 CR?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CF377.4 CR by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form CF377.4 CR "Calfresh Notice of Change for Change Reporting Households" - California

1303 times
Rate (4.5 / 5) 78 votes
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH NOTICE OF CHANGE
FOR CHANGE REPORTING
Notice Date
:
HOUSEHOLDS
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone
:
Address
:
If you have any questions or want more information
(ADDRESSEE)
about this action, please contact your worker.
State Hearing: If you think this
action is wrong, you can ask for a
hearing unless you already had a
hearing on the amount you owe. The
back of this page tells how. Your
benefits may not be changed if you
ask for a hearing before this action
takes place.
CHANGE IN BENEFITS
NO CHANGE IN BENEFITS
Your CalFresh benefits did not change as a result of the
Effective________________, your CalFresh benefits are changed
document(s)/information we received because:
from $______________ to $_______________each month because:
You have already been told about an overissuance of CalFresh
TERMINATION
benefits and you are getting less CalFresh benefits because the
County has been reducing your monthly allotment by 10% or
Effective____________________, your CalFresh benefits are
$10 (whichever is more) to pay back the CalFresh benefits that
you got and should not have. It has been decided in court or by
terminated because:
a state hearing or because you signed a Disqualification
Consent Agreement or an Administrative Disqualification
Hearing Waiver that this overissuance is an Intentional Program
Violation (IPV). Now your monthly allotment is being changed
because the County can begin reducing your allotment by 20%
or $10 (whichever is more). If there are any other changes to
your monthly CalFresh allotment, this form will tell you.
Based on the reason your benefits are terminated, your
household is also disqualified from participating in the
PROPOSED CHANGE IN BENEFITS
CalFresh Program until________________. You may
reapply for benefits at the end of this disqualification period.
Effective____________________, your CalFresh benefits may
be reduced or terminated because information needed to
determine your continued eligibility or the correct amount of your
benefits was not received with your Change Repor t
(CF 377.5 CR). We must receive the following information by no
later than the first day of next month:
If verification of an expense is requested and if you do not
provide it, the expense will not be allowed when computing next
month’s benefits. Also, if you do not provide other requested
information, your benefits may be reduced or terminated.
Rules: These rules apply to the above action(s):
You may review them at your welfare office.
CF 377.4 CR (1/14) REQUIRED FORM - SUBSTITUTE PERMITTED
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH NOTICE OF CHANGE
FOR CHANGE REPORTING
Notice Date
:
HOUSEHOLDS
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone
:
Address
:
If you have any questions or want more information
(ADDRESSEE)
about this action, please contact your worker.
State Hearing: If you think this
action is wrong, you can ask for a
hearing unless you already had a
hearing on the amount you owe. The
back of this page tells how. Your
benefits may not be changed if you
ask for a hearing before this action
takes place.
CHANGE IN BENEFITS
NO CHANGE IN BENEFITS
Your CalFresh benefits did not change as a result of the
Effective________________, your CalFresh benefits are changed
document(s)/information we received because:
from $______________ to $_______________each month because:
You have already been told about an overissuance of CalFresh
TERMINATION
benefits and you are getting less CalFresh benefits because the
County has been reducing your monthly allotment by 10% or
Effective____________________, your CalFresh benefits are
$10 (whichever is more) to pay back the CalFresh benefits that
you got and should not have. It has been decided in court or by
terminated because:
a state hearing or because you signed a Disqualification
Consent Agreement or an Administrative Disqualification
Hearing Waiver that this overissuance is an Intentional Program
Violation (IPV). Now your monthly allotment is being changed
because the County can begin reducing your allotment by 20%
or $10 (whichever is more). If there are any other changes to
your monthly CalFresh allotment, this form will tell you.
Based on the reason your benefits are terminated, your
household is also disqualified from participating in the
PROPOSED CHANGE IN BENEFITS
CalFresh Program until________________. You may
reapply for benefits at the end of this disqualification period.
Effective____________________, your CalFresh benefits may
be reduced or terminated because information needed to
determine your continued eligibility or the correct amount of your
benefits was not received with your Change Repor t
(CF 377.5 CR). We must receive the following information by no
later than the first day of next month:
If verification of an expense is requested and if you do not
provide it, the expense will not be allowed when computing next
month’s benefits. Also, if you do not provide other requested
information, your benefits may be reduced or terminated.
Rules: These rules apply to the above action(s):
You may review them at your welfare office.
CF 377.4 CR (1/14) REQUIRED FORM - SUBSTITUTE PERMITTED
TO ASK FOR A HEARING:
YOUR HEARING RIGHTS
Fill out this page.
You have the right to ask for a hearing if you disagree with
Make a copy of the front and back of this page for your records.
any county action. You have only 90 days to ask for a
If you ask, your worker will get you a copy of this page.
hearing. The 90 days started the day after the county gave or
Send or take this page to:
mailed you this notice. If you have good cause as to why
you were not able to file for a hearing within the 90 days, you
may still file for a hearing. If you provide good cause, a
hearing may still be scheduled.
OR
If you ask for a hearing before an action on Cash Aid,
Call toll free: 1-800-952-5253 or for hearing or speech impaired
Medi-Cal, CalFresh, or Child Care takes place:
who use TDD, 1-800-952-8349.
Your Cash Aid or Medi-Cal will stay the same while you wait for a
To Get Help: You can ask about your hearing rights or for a legal
hearing.
aid referral at the toll-free state phone numbers listed above. You
Your Child Care Services may stay the same while you wait for a
may get free legal help at your local legal aid or welfare rights office.
hearing.
Your CalFresh benefits will stay the same until the hearing or the
end of your certification period, whichever is earlier.
If the hearing decision says we are right, you will owe us for any
extra Cash Aid, CalFresh or Child Care Services you got.
To let
If you do not want to go to the hearing alone, you can bring a
us lower or stop your benefits before the hearing, check below:
friend or someone with you.
Yes, lower or stop:
Cash Aid
CalFresh
HEARING REQUEST
Child Care
I want a hearing due to an action by the Welfare Department
of ________________________________ County about my:
While You Wait for a Hearing Decision for:
n
n
n
Cash Aid
CalFresh
Medi-Cal
Welfare to Work:
n
Other (list)___________________________________________
You do not have to take part in the activities.
Here's Why: ____________________________________________
You may receive child care payments for employment and for
activities approved by the county before this notice.
_______________________________________________________
If we told you your other supportive services payments will stop, you
_______________________________________________________
will not get any more payments, even if you go to your activity.
If we told you we will pay your other supportive services, they will be
_______________________________________________________
paid in the amount and in the way we told you in this notice.
_______________________________________________________
To get those supportive services, you must go to the activity the
county told you to attend.
_______________________________________________________
If the amount of supportive services the county pays while you
n
wait for a hearing decision is not enough to allow you to
If you need more space, check here and add a page.
participate, you can stop going to the activity.
n
I need the state to provide me with an interpreter at no cost to me.
(A relative or friend cannot interpret for you at the hearing.)
Cal-Learn:
You cannot participate in the Cal-Learn Program if we told you
My language or dialect is: ____________________________
we cannot serve you.
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
We will only pay for Cal-Learn supportive services for an
approved activity.
BIRTH DATE
PHONE NUMBER
STREET ADDRESS
OTHER INFORMATION
Medi-Cal Managed Care Plan Members: The action on this notice may stop
CITY
STATE
ZIP CODE
you from getting services from your managed care health plan. You may wish
to contact your health plan membership services if you have questions.
SIGNATURE
DATE
Child and/or Medical Support: The local child support agency will help
NAME OF PERSON COMPLETING THIS FORM
PHONE NUMBER
collect support at no cost even if you are not on cash aid. If they now collect
support for you, they will keep doing so unless you tell them in writing to stop.
n
I want the person named below to represent me at this
They will send you current support money collected but will keep past due
money collected that is owed to the county.
hearing. I give my permission for this person to see my
records or go to the hearing for me. (This person can be a
Family Planning: Your welfare office will give you information when you ask
friend or relative but cannot interpret for you.)
for it.
Hearing File: If you ask for a hearing, the State Hearing Division will set up a
NAME
PHONE NUMBER
file. You have the right to see this file before your hearing and to get a copy of
the county's written position on your case at least two days before the hearing.
STREET ADDRESS
The state may give your hearing file to the Welfare Department and the U.S.
Departments of Health and Human Services and Agriculture.
(W&I Code
CITY
STATE
ZIP CODE
Sections 10850 and 10950.)
NA BACK 9 (REPLACES NA BACK 8 AND EP 5) (REVISED 4/2013) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
Page of 2