STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
YOU DO NOT OWE ANYTHING FOR RECEIVING CALFRESH BENEFITS
We received your payment dated and signed by in the
amount of dollars ($ ) to repay CalFresh benefits received by you in
the past. You received CalFresh legally and are under no obligation to make any repayments.
However, if you wish to make a voluntary donation, you can make it payable to the FOOD AND
NUTRITION SERVICE (FNS). You can send us the payment for processing, and we will forward it to
the appropriate FNS office. DO NOT SEND CASH.
If you send a voluntary donation, you must complete the attached release form and return it, along
with your voluntary donation, to our office located at:
Information on your donation(s) will not be disclosed to the U.S. Consulate General Office unless you
authorize us in writing to do so.
If you have any questions regarding this notice, you may contact:
Name: Phone:
CF 20 (2/14)
