Dfa 1239 Form – Fill Out and Use This PDF

CALFRESH NOTICE OF	COUNTY OF
APPROVAL/DENIAL/TERMINATION
TRANSITIONAL BENEFITS

STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Notice Date :

Case

Name :

Case

Number :

Worker

Name :

Worker

Number :

Telephone :

Address :

■Approval

As of ______________________________, your CalFresh benefits are

MM/DD/CCYY

$ __________ each month.

Because your CalWORKs case has been closed, you will get Transitional CalFresh benefits. You will get Transitional CalFresh benefits starting _______________ and ending ________________.

MM/CCYY

MM/CCYY

This replaces your previous certification period.

Your Transitional CalFresh benefits will end after 5 months unless your household recertifies.

Reporting:

You are encouraged to report if you change your address. Households that get Transitional CalFresh benefits do not have to turn in a reporting form.

Recertification:

You will get a notice when it is time to recertify at the end of the 5-month Transitional CalFresh period.

●You may ask to recertify for regular CalFresh at any time during the Transitional CalFresh period. If you ask to recertify during the first four months of the Transitional CalFresh period and the regular CalFresh benefits are lower than the current Transitional CalFresh amount, you may withdraw your request for recertification.

●If you apply and are approved for CalWORKs and regular CalFresh, you will have a new certification period. Eligibility for Transitional CalFresh will end when the CalWORKs and regular CalFresh benefits are approved, even if your 5 months have not ended.

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.

■Denial/Withdrawal

As of _________________, the CalFresh recertification you asked for

MM/DD/CCYY

during the first 4 months of Transitional CalFresh benefits was not approved. Your current Transitional CalFresh benefit will continue until the end of the Transitional CalFresh benefit period.

Here’s Why:

■You have withdrawn your request for recertification for regular CalFresh benefits.

■You did not give us the information we asked for within 10 days of the date requested.

■You did not complete your scheduled interview.

■Other (see below):

■Termination

As of _______________________, your current Transitional CalFresh

MM/DD/CCYY

benefit period will end.

Here’s Why:

■Your application for CalWORKs has been approved.

■Your application for CalFresh has been approved.

■Your CalWORKs and/or CalFresh benefits have been restored.

■Other (see below):

Rules: These rules apply: MPP § 63-504.6, MPP § 63-504.13. You may review them at your welfare office.

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 (Food Stamps), 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 (Food Stamps) will stay the same until the hearing or the end of your certification period, whichever is earlier.

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 the hearing decision says we are right, you will owe us for any extra Cash Aid, CalFresh (Food Stamps) 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 (Food Stamps)

■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.)

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:

Cash Aid CalFresh (Food Stamps) Medi-Cal

Other (list) ___________________________________________

Here's Why: ____________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

If you need more space, check here and add a page.

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

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