Form CF377.11A "CalFresh Time Limit Notice - Expiration of Three Consecutive Months for Able-Bodied Adults Without Dependents (Abawds)" - California

What Is Form CF377.11A?

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 June 1, 2018;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form CF377.11A by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form CF377.11A "CalFresh Time Limit Notice - Expiration of Three Consecutive Months for Able-Bodied Adults Without Dependents (Abawds)" - California

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CALFRESH TIME LIMIT NOTICE
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
EXPIRATION OF THREE CONSECUTIVE
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MONTHS FOR ABLE-BODIED ADULTS WITHOUT
Notice Date
: ___________________________________________________________
DEPENDENTS (ABAWDs)
Case Name
: ___________________________________________________________
Case Number
: ___________________________________________________________
Worker Name
: ___________________________________________________________
Worker Number
: ___________________________________________________________
Telephone Number : ___________________________________________________________
Address
: ___________________________________________________________
(ADDRESSEE)
___________________________________________________________
Questions? Ask your worker.
State Hearing: If you think this action is
wrong, you can ask for a hearing. The
back of this page tells how. Your benefits
may not be changed if you ask for a
hearing before this action takes place.
• Applying for or getting unemployment insurance benefits (UIB);
Starting ______________, _________________________ will get
CalFresh for ____________, ____________ and ____________.
• Chronically homeless;
• Struggling with drugs or alcohol;
Starting ________________, CalFresh will be stopped for
• A victim of domestic violence;
_____________________.
• Going to school at least half-time (additional student
eligibility rules may apply);
You will be required to work, be excused from the work
• Pregnant;
requirement or have a good reason for not meeting the work
requirement in order to get CalFresh for more than three months
• Living with a child under age 18 who is part of your CalFresh
within the 36-month period.
household, even if they are not eligible for CalFresh (this
can be your own child, sibling or the child of another person
REASONS YOU ARE GETTING CALFRESH ONLY FOR
living in the home who is part of the CalFresh household);
THREE MONTHS IN A ROW
• Caring for a dependent child under age 6 or a sick or
injured person who will need your help for more than 30
• Your CalFresh was stopped once before because you did not
days (the child or sick or injured person does not have to
meet the work requirement for three months; and
be a CalFresh member or living in the home); or
• You were not excused from the work requirement or you did not
• Meeting or excused from the CalWORKs Welfare-to-Work
provide a good reason for not meeting the work requirement.
rules.
HOW TO KEEP GETTING CALFRESH
If you think you meet the work requirement, may be excused
• When the three months stops, you can keep CalFresh if you
from the work requirement or have a good reason for not
meet the work requirement. You can meet the work requirement
meeting the work requirement, contact your county as soon
by showing proof that for at least 20 hours per week on
as possible.
average or 80 hours per month, you are:
IF YOU LOSE CALFRESH, YOU MAY REAPPLY
• Working, including self-employment;
• Going to school or training;
• If you meet the work requirement during a period of 30 days in
a row.
• Doing volunteer work, community service or in-kind work
(working in exchange for goods or services instead of
• At any time if you become excused from the work requirement.
money);
• If you move to an area where the time limit is waived.
• Participating in Employment & Training (E&T);
• On or after January 1, 2020 when the 36-month period restarts.
• Participating in job search up to 9 hours per week in
36-MONTH PERIOD
combination with other work activities; or
During a 36-month period you can only get CalFresh for three
• Doing a combination of any of the above.
months unless you meet the ABAWD work requirement or are
• Go to workfare for the number of hours determined by the
excused from the work requirement. Call the county at that time
county, if available.
and explain your situation.
• Have a good reason, such as you were ill, were caring for a
MANDATORY REPORTS
sick or injured person, had an emergency, or had no
You are required to contact the county when you have either:
transportation available.
• Received gross monthly income over the Income Reporting
• Meet one of the following excuses from the work requirement:
Threshold (IRT); or
• Under age 18 or over age 49;
• A reduction in ABAWD work hours below 20 hours per week
• Physically or mentally unable to work 20 hours per week for
for a total of 80 hours per month.
a total of 80 hours per month;
RULES: These rules apply. You may review them at your county
• Applying for or getting disability benefits (including veterans
office. MPP Section 63-410
disability benefits);
PAGE ___OF ___
CF 377.11A (6/18) REQUIRED FORM - NO SUBSTITUTES PERMITTED
CALFRESH TIME LIMIT NOTICE
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
EXPIRATION OF THREE CONSECUTIVE
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MONTHS FOR ABLE-BODIED ADULTS WITHOUT
Notice Date
: ___________________________________________________________
DEPENDENTS (ABAWDs)
Case Name
: ___________________________________________________________
Case Number
: ___________________________________________________________
Worker Name
: ___________________________________________________________
Worker Number
: ___________________________________________________________
Telephone Number : ___________________________________________________________
Address
: ___________________________________________________________
(ADDRESSEE)
___________________________________________________________
Questions? Ask your worker.
State Hearing: If you think this action is
wrong, you can ask for a hearing. The
back of this page tells how. Your benefits
may not be changed if you ask for a
hearing before this action takes place.
• Applying for or getting unemployment insurance benefits (UIB);
Starting ______________, _________________________ will get
CalFresh for ____________, ____________ and ____________.
• Chronically homeless;
• Struggling with drugs or alcohol;
Starting ________________, CalFresh will be stopped for
• A victim of domestic violence;
_____________________.
• Going to school at least half-time (additional student
eligibility rules may apply);
You will be required to work, be excused from the work
• Pregnant;
requirement or have a good reason for not meeting the work
requirement in order to get CalFresh for more than three months
• Living with a child under age 18 who is part of your CalFresh
within the 36-month period.
household, even if they are not eligible for CalFresh (this
can be your own child, sibling or the child of another person
REASONS YOU ARE GETTING CALFRESH ONLY FOR
living in the home who is part of the CalFresh household);
THREE MONTHS IN A ROW
• Caring for a dependent child under age 6 or a sick or
injured person who will need your help for more than 30
• Your CalFresh was stopped once before because you did not
days (the child or sick or injured person does not have to
meet the work requirement for three months; and
be a CalFresh member or living in the home); or
• You were not excused from the work requirement or you did not
• Meeting or excused from the CalWORKs Welfare-to-Work
provide a good reason for not meeting the work requirement.
rules.
HOW TO KEEP GETTING CALFRESH
If you think you meet the work requirement, may be excused
• When the three months stops, you can keep CalFresh if you
from the work requirement or have a good reason for not
meet the work requirement. You can meet the work requirement
meeting the work requirement, contact your county as soon
by showing proof that for at least 20 hours per week on
as possible.
average or 80 hours per month, you are:
IF YOU LOSE CALFRESH, YOU MAY REAPPLY
• Working, including self-employment;
• Going to school or training;
• If you meet the work requirement during a period of 30 days in
a row.
• Doing volunteer work, community service or in-kind work
(working in exchange for goods or services instead of
• At any time if you become excused from the work requirement.
money);
• If you move to an area where the time limit is waived.
• Participating in Employment & Training (E&T);
• On or after January 1, 2020 when the 36-month period restarts.
• Participating in job search up to 9 hours per week in
36-MONTH PERIOD
combination with other work activities; or
During a 36-month period you can only get CalFresh for three
• Doing a combination of any of the above.
months unless you meet the ABAWD work requirement or are
• Go to workfare for the number of hours determined by the
excused from the work requirement. Call the county at that time
county, if available.
and explain your situation.
• Have a good reason, such as you were ill, were caring for a
MANDATORY REPORTS
sick or injured person, had an emergency, or had no
You are required to contact the county when you have either:
transportation available.
• Received gross monthly income over the Income Reporting
• Meet one of the following excuses from the work requirement:
Threshold (IRT); or
• Under age 18 or over age 49;
• A reduction in ABAWD work hours below 20 hours per week
• Physically or mentally unable to work 20 hours per week for
for a total of 80 hours per month.
a total of 80 hours per month;
RULES: These rules apply. You may review them at your county
• Applying for or getting disability benefits (including veterans
office. MPP Section 63-410
disability benefits);
PAGE ___OF ___
CF 377.11A (6/18) REQUIRED FORM - NO SUBSTITUTES 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 hearing.
If you ask, your worker will get you a copy of this page.
The 90 days started the day after the county gave or mailed
Send or take this page to:
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 us
If you do not want to go to the hearing alone, you can bring a
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:
Cash Aid
CalFresh
Medi-Cal
Welfare to Work:
Other (list) ___________________________________________
You do not have to take part in the activities.
You may receive child care payments for employment and for activities
Here’s Why: _____________________________________________
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 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.
I need the state to provide me with an interpreter at no cost to me.
Cal-Learn:
(A relative or friend cannot interpret for you at the hearing.)
My language or dialect is: ____________________________
You cannot participate in the Cal-Learn Program if we told you
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.
They will send you current support money collected but will keep past due
I want the person named below to represent me at this
money collected that is owed to the county.
hearing. I give my permission for this person to see my
Family Planning: Your welfare office will give you information when you ask
records or go to the hearing for me. (This person can be a
for it.
friend or relative but cannot interpret for you.)
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
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