Form Na 994 - Food Stamp Notice Of Discontinuance - Failure To Meet Non-Assistance Cfap Work Requirement (Violation Prior To Three Consecutive Month Grace Period)
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1
2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
FOOD STAMP NOTICE OF
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DISCONTINUANCE
NOTICE DATE :
________________________________________________________________________
CASE
Failure To Meet Non-Assistance CFAP Work
NAME
:
________________________________________________________________________
Requirement (violation prior to three consecutive
NUMBER
:
________________________________________________________________________
WORKER
month grace period)
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.
As of _____________________________, food stamps received under the California Food Assistance Program (CFAP) will be discontinued for
______________. The County is taking this action because ________________________________ has not followed the Non-Assistance
CFAP work rule for:
First failed month/year________________________
Second failed month/year _____________________ and
Has not provided proof that the Non-Assistance work rule has been met for the third failed month/year______________________________
Did not meet the Non-Assistance work rule for the third failed month/year____________________________________________________.
This is the first time in the 36-month period that started __________________________ that this person had their food stamps discontinued for
not following the Non-Assistance CFAP work rule. A person who is not excused from the Non-Assistance work rule cannot receive food stamps
for more than three months without meeting this work rule. The Non-Assistance work rule says that each month a person must work an average
of 20 hours or more per week, participate in a workfare assignment, or participate in a work assignment for 20 or more hours per week.
To get food stamps again, ___________________ must be eligible. To be eligible, that person must:
•
Be excused from the Non-Assistance work rule: or
•
Show proof that they either followed the Non-Assistance work rule or were excused for any or all of the months listed above; or
•
Work 80 or more hours in a 30-day period, participate in a workfare assignment for the required number of hours in a 30-day period, or
participate in a work assignment 80 or more hours in a 30-day period.
Even if you do not become excused or follow the Non-Assistance work rule, you may become eligible again when the 36 month period ends on
_______________________. You may reapply at that time.
If your household had other changes you will get another notice.
If the failure to meet the non-assistance work rule also caused a food stamp penalty, that person may not be able to get food stamps
for at least 1, 3 or 6 months. That person will get another notice telling them how long their food stamps will be stopped.
COMMENTS
RULES: These rules apply. You may review them at your welfare office.
MPP
63-407.5
63-410
W&IC 18930.5
All County Letter 99-78
Other_________________________________
NA 994 (11/00)
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