Form Qr 377.4 - Food Stamp Notice Of Change For Quarterly Reporting Household
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1
2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOOD STAMP NOTICE OF CHANGE
FOR QUARTERLY REPORTING
Notice Date
:
HOUSEHOLD
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: You can ask for a hearing if you
believe the action is wrong. The back of this page tells
how to ask for a hearing. If you already had a hearing
on the cause of the overissuance that is being
collected, you cannot ask for a new hearing, unless
you think the new amount of food stamp benefits you
are getting because of the overissuance collection is
incorrect.
CHANGE IN BENEFITS
NO CHANGE IN BENEFITS
Your food stamp benefits in this quarter did not change as a result of
Effective________________, your food stamp benefits are changed
the document(s) /information we received because:
from $______________ to $_______________each month because:
Any changes you voluntarily reported must be reported again on
your next Quarterly Report (QR 7), along with proof of the
change.
You have already been told about an overissuance of food
stamps and you are getting less food stamps because the
County has been reducing your monthly allotment by 10%
TERMINATION
or $10 (whichever is more) to pay back the food stamps that
you got and should not have. It has been decided in court
Effective____________________, your food stamp benefits are
or by a state hearing or because you signed a
Disqualification Consent Agreement or an Administrative
terminated because:
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 food stamp
Based on the reason your benefits are terminated, your
allotment, this form will tell you.
household is also disqualified from participating in the Food
PROPOSED CHANGE IN BENEFITS
Stamp Program until________________. You may reapply
for benefits at the end of this disqualification period.
Effective____________________, your food stamp benefits may
be reduced or terminated because information needed to
COMMENTS
determine your continued eligibility or the correct amount of your
benefits was not received with your Quarterly Eligibility Status
Report (QR 7). We must receive the following information by no
later than the first day of next month:
If verification of an expense is requested and you do not provide
it, the expense will not be allowed when computing next
quarter’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.
QR 377.4 (1/04) QUARTERLY REPORTING - REQUIRED FORM - SUBSTITUTE PERMITTED
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