NOTICE OF APPROVAL/DENIAL
FOR DISASTER CALFRESH
COUNTY OF
Notice Date :
Case
Name :
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Number :
Worker
Name :
Number :
Telephone:
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.
Your application for Disaster CalFresh benefits has been approved. Your certification covers the disaster benefit period from
___________________ through ____________________.
Your one time Disaster CalFresh benefit allotment for a household of
__________ is ___________________.
Your application for Disaster CalFresh benefits has been denied because of the following:
You failed to appear for the Disaster CalFresh interview.
You did not live or work in the disaster area at the time of the disaster.
Your income and resources exceed the income and resource limits for the Disaster CalFresh Program.
Other ____________________________________________________________________________.
The table below shows how we calculated the Disaster CalFresh benefit for your household. We used the information you gave
us on the Application for Disaster CalFresh (DFA 385) to determine your household’
s Disaster CalFresh benefit amount.
Disaster CalFresh Benefit Calculation:
a. Anticipated Income $
b. Accessible Cash
Resources
(+)
c. Total disaster period
income = (a+b)
(=)
d. Total allowable disaster
related e
xpenses
(-)
e. Accessib
le disaster period
income = (c-d)
(=)
f. Maximum Disaster Income
Limit for Household size
(use information from
Disaster Table)
Household
size:
If (e) is equal to or less than (f), the household is eligible.
g.
Disaster Allotment
(from Disaster Table)
h. Regular allotment already
received (if an
y)
(-)
i. Net disaster allotment (g-h)
(=)
Rules: These r
ules apply. MPP 63-900
Y
ou may review them at your welfare office.
DFA 390 (9/11) REQUIRED FORM -NO SUBSTITUTE PERMITTED
YOUR HEARING RIGHTS
You have the right to ask for a hearing if you disagree with
any county action. You have only 90 days to ask for a
hearing. The 90 days started the day after the county gave or
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.
If you ask for a hearing before an action on Cash Aid,
Medi-Cal, CalFresh, or Child Care takes place:
Your Cash Aid or Medi-Cal will stay the same while you wait for a
hearing.
Your Child Care Services may stay the same while you wait for a
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 lower or stop your benefits before the hearing, check below:
Yes, lower or stop:
Cash Aid
CalFresh
Child Care
While You Wait for a Hearing Decision for:
Welfare to Work:
You do not have to take part in the activities.
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
wait for a hearing decision is not enough to allow you to
participate, you can stop going to the activity.
Cal-Learn
:
You cannot participate in the Cal-Learn Program if we told you
we cannot serve you.
We will only pay for Cal-Learn supportive services for an
approved activity.
OTHER INFORMATION
Medi-Cal Managed Care Plan Members: The action on this notice may stop
you from getting services from your managed care health plan. You may wish
to contact your health plan membership services if you have questions.
Child and/or Medical Support: The local child support agency will help
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
money collected that is owed to the county.
Family Planning: Your welfare office will give you information when you ask
for it.
Hearing File: If you ask for a hearing, the State Hearing Division will set up a
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.
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
Sections 10850 and 10950.)
TO ASK FOR A HEARING:
Fill out this page.
Make a copy of the front and back of this page for your records.
If you ask, your worker will get you a copy of this page.
Send or take this page to:
OR
Call toll free: 1-800-952-5253 or for hearing or speech impaired
who use TDD, 1-800-952-8349.
To Get Help: You can ask about your hearing rights or for a legal
aid referral at the toll-free state phone numbers listed above. You
may get free legal help at your local legal aid or welfare rights office.
If you do not want to go to the hearing alone, you can bring a
friend or someone with you.
HEARING REQUEST
I want a hearing due to an action by the Welfare Department
of ________________________________ County about my:
n Cash Aid n CalFresh n Medi-Cal
n Other (list)___________________________________________
Here's Why: ____________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
n
If you need more space, check here and add a page.
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.)
My language or dialect is: ____________________________
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
BIRTH DATE PHONE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
SIGNATURE DATE
NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER
n I want the person named below to represent me at this
hearing. I give my permission for this person to see my
records or go to the hearing for me. (This person can be a
friend or relative but cannot interpret for you.)
NAME PHONE NUMBER
STREET ADDRESS
CITY STATE
ZIP CODE
NA BACK 9 (REPLACES NA BACK 8 AND EP 5) (REVISED 4/2013) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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