DPSS Customer Service Center V STATE OF CALIFORNIA

COUNTY OF LOS ANGELES HEALTH AND WELFARE AGENCY

3400 AERO JET AVE
CALIFORNIA DEPARTMENT OF SOCIAL
EL MONTE, CA 91731-2803
SERVICES

NOTICE DATE: May 22, 2024

CASE NAME: FRANZ GREY
CASE NUMBER: B0DVK77
WORKER NAME: Melina Amiri
WORKER ID: 19DPZG490B
TELEPHONE NUMBER: (866) 613-3777
CUSTOMER ID: 1848603716
CALFRESH NOTICE OF
APPROVAL

FRANZ GREY
6215 HOLLY MONT DR
LOS ANGELES, CA 90068-3307

Questions? Ask your worker.

✔ YOUR APPLICATION FOR CALFRESH BENEFITS State Hearing: If you think this action is wrong, you
HAS BEEN APPROVED. Your initial amount of can ask for a hearing. The back page tells you how.
benefits is: $150.00 for 05/2024. Your benefit amount Your benefits may not be changed if you ask for a
per month for the rest of your certification period will hearing before this action takes place.
be $291.00 from 06/01/2024 through 04/30/2027.

CalFresh Budget
IF YOU ALSO APPLIED FOR CASH AID, and it has not
yet been approved, your CalFresh benefits may be
Report Month 05/2024
lowered or stopped without another notice if your cash aid
is approved.
Household Size 1

✔ Your first month’s benefits include more than one Total Countable Earned Income $0.00
month’s benefits because of the date your application Adjusted Countable Earned Income $0.00
was approved. Total Countable Unearned Income $0.00
Your first month’s benefits were prorated from the Net Countable Income $0.00
✔
date you filled your application.
Standard Deduction $198.00
Dependent Care $0.00
Homeless Shelter Deduction $0.00
Excess Medical Expense for Aged/Disabled $0.00
Total Deductions $198.00

Preliminary Adjusted Income $0.00

Housing Expenses $0.00
Utility Expenses $0.00
Adjusted Net Income $0.00

CalFresh Allotment $150.00

Less Overissuance -$0.00
Rules: These rules apply; you may review them at your welfare office:
63-301.32, 63-301.51 Total CalFresh Allotment =$150.00

CF 377.1 Page 1 of 2

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California Health & Human Services Agency California Department of Social Services

YOUR HEARING RIGHTS

YOUR HEARING RIGHTS (See also PUB 412 at www.cdss.ca.gov/inforesources/state-hearings )
You can ask for a hearing if you disagree with a county/agency action or failure to act. You have 90 days to do so,
starting the day after the date of the notice. After 90 days, you must prove you had a good reason for asking late. You
can also ask for a hearing to review your benefits for the past 90 days. If you ask for a hearing before the date of the
change, your benefits will continue unchanged. CalFresh will end if you don’t recertify when due.
• Online at acms.dss.ca.gov Click "Create an account" to • Fill out this page, and deliver it by one of the following:
have an ACMS account and get documents online; or click o In-person: Appeals and State Hearings Section
“Submit Appeal without Account” to file without an account 3833 S. Vermont Ave.
OR 4th Floor
Los Angeles, CA 90037
• Call toll free (800) 743-8525 (or TDD (800) 952-8349 ) OR (800) 952-8349 / Fax: (833) 281-0905
Toll Free: (800) 743-8525
• Fax fill out this page/fax to (833) 281-0905 OR
o Mail to: CDSS State Hearings Division, PO Box 944243,
MS 21-37 Sacramento CA 94244-2430

o Email to: [email protected]

HEARING REQUEST
1. My hearing issue involves (benefit program)
and LOS ANGELES County/Agency.
2. I want a hearing because:

3. Print name of person who needs a hearing: Birthdate:

4. Mailing Address: Phone number:
I want to get hearing notices from the State Hearing Division by email. Email Address:
5. Name/Signature: Date Signed
6. Interpreter: I want a free interpreter for the language or dialect.
7. Disability Accommodation for hearing? No Yes (explain):
8. Your Hearing will be scheduled by phone. If you want your hearing conducted by a different method, tell us how:
By Telephone By Video (you see judge on your phone/computer) In person at the county hearing site
I have no phone or internet access. I want to go and use the phone or video at hearing site for my hearing.
9. I need a faster scheduled hearing due to Denial of CalWORKs or CalFresh emergency benefits
Medical Emergency Eviction/homelessness Other (explain):
10. If you timely appeal before the action listed in the notice takes place, your aid may stay the same. For CalWORKs
(including Child Care) and CalFresh, if the county action was correct, you have to pay back any extra aid.
Check to have your aid lowered or stopped pending the hearing for: CalWORKs Childcare CalFresh
11. You can have a friend, relative, legal counsel or other person help with your hearing. If they have agreed:
NAME: Email:
Address: Phone:
12. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing:
Legal Aid Foundation of Los Angeles (LAFLA)
(800) 399-4529
Neighborhood Legal Services of Los Angeles County (NLSLA)
(800) 433-6251

NA Back 9 (5/22) Required Form - No Substitute Permitted

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 STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
NOTICE OF ACTION HEALTH AND WELFARE AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL
Continuation Page SERVICES

NOTICE DATE: May 22, 2024

CASE NAME: FRANZ GREY
CASE NUMBER: B0DVK77
WORKER NAME: Melina Amiri
WORKER ID: 19DPZG490B
TELEPHONE NUMBER: (866) 613-3777
CUSTOMER ID: 1848603716

For CalFresh, your family size is 1.

Your IRT is $1,580.00.

Your CalFresh household may be eligible to a State

Utility Assistance Subsidy (SUAS) payment. If eligible,
the county will award you a $20.01 SUAS cash
payment. This is a one-time per year payment and if
eligible it will be put into your cash Electronic Benefit
Transfer (EBT) account. If you do not have a cash EBT
account, one will be set up for you on your CalFresh
EBT card. You will not have to do anything to get a new
card, but you can use it to cover expenses not
otherwise covered by CalFresh. This payment allows
the county to use the highest utility deduction (Standard
Utility Allowance - SUA) for food benefits. You may use
this $20.01 when you use your EBT card. If you want to
know more, please contact your local county office.

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