Fillable DENIED - Reason for Denial (Explain) (CF 303) (California)

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DENIED - Reason for Denial (Explain) (CF 303) (California)

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I,____________________________________________________,
declare that the household:
■■ Electronic Benefits Transfer (EBT) card was not received in the
mail at the address below and the benefits have been transacted
by an unauthorized person:
■■ EBT card was reported lost/stolen to the county or to EBT
hotline and the county, or the EBT hotline failed to cancel the
EBT card and the benefits have been transacted by an
unauthorized person.
Reported on ________________________ at ______________
to_________________________________________________
■■ Food destroyed in household misfortune or disaster. What
happened and when:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
I declare the above statement is true and correct to the best of my
knowledge. I also understand that if I give wrong or incomplete facts
I may be disqualified from the CalFresh Program, fined, imprisoned,
or all three.
Mailing Address (Number, Street, P.O. Box)
_________________________________________________
City State Zip
_________________________________________________
Home Address (If Different) (Number, Street)
_________________________________________________
City State Zip
_________________________________________________
DATE
TIMEDATE
RECEIVED BY:
SIGNATURE (PERSON AUTHORIZING OR DENYING REQUEST)
DATE
DATE
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REPLACEMENT AFFIDAVIT/AUTHORIZATION
(CF 303)
Instructions: In Part A check which box(es) apply to you, sign and
return this form within 10 days of your reported loss or no
replacement can be made.
Case Name:
Case Number:
Worker:
Date CF 303 Received:
COUNTY USE ONLY
PART A - HOUSEHOLD AFFIDAVIT
PART B - REPLACEMENT BENEFITS
PART C - ACKNOWLEDGEMENT OF RECEIPT (OVER THE
COUNTER)
SIGNATURE OF RESPONSIBLE HOUSEHOLD MEMBER OR
REPRESENTATIVE (WHO GOT REPLACEMENT)
CF 303 (2/14) REQUIRED FORM - SUBSTITUTES PERMITTED
☛
■■ APPROVED - EBT Replacement Date _____________________
■■ EBT: Authorized Replacement Amount $___________________
■■ DENIED - Reason for Denial (Explain)
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Rules: These rules may apply and you may review at your welfare
office MPP 16-515.
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DENIED - Reason for Denial (Explain) (CF 303) (California)

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Completed 25 July 2021

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