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    Approval

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    Approval

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    Approval

    Uploaded by

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    of 4

    067 Lancaster General Relief Office STATE OF CALIFORNIA

    COUNTY OF LOS ANGELES HEALTH AND WELFARE AGENCY


    337 E AVENUE K10
    CALIFORNIA DEPARTMENT OF SOCIAL
    LANCASTER, CA 93535-4539
    SERVICES

    NOTICE DATE: May 03, 2024


    CASE NAME: CHARLETTE D CARPENTER
    CASE NUMBER: B0PWV23
    WORKER NAME: Customer Service
    WORKER ID: 19DP67146L
    TELEPHONE NUMBER: (866) 613-3777
    CUSTOMER ID: 1850508341
    CALFRESH NOTICE OF
    APPROVAL

    CHARLETTE D CARPENTER
    1819 CHARLIE SIFFORD DR
    LOS ANGELES, CA 90047-5102

    Questions? Ask your worker.

    YOUR APPLICATION FOR CALFRESH BENEFITS State Hearing: If you think this action is wrong, you
    HAS BEEN APPROVED. can ask for a hearing. The back page tells you how.
    Your benefits may not be changed if you ask for a
    Your initial amount of benefits is: $78.00 for 05/2024. hearing before this action takes place.
    Your benefit amount per month for the rest of your
    certification period will be $84.00 from 06/01/2024
    through 04/30/2025.
    CalFresh Budget
    For CalFresh, your family size is 1. Your IRT is
    $1,580.00. Report Month 05/2024
    IF YOU ALSO APPLIED FOR CASH AID, and it has
    not yet been approved, your CalFresh benefits may be Household Size 1
    lowered or stopped without another notice if your cash
    aid is approved. Total Countable Earned Income $1,317.69
    Adjusted Countable Earned Income $1,054.15
    The amounts used to figure your CalFresh are shown Total Countable Unearned Income $0.00
    on this notice. If your case contains a disqualified Net Countable Income $1,054.15
    person(s) and that/those person(s) has/have income, all
    of their income is used to compute your CalFresh Standard Deduction $198.00
    allotment. Dependent Care $0.00
    Homeless Shelter Deduction $0.00
    Your CalFresh household may be eligible to a State
    Excess Medical Expense for Aged/Disabled $0.00
    Utility Assistance Subsidy (SUAS) payment. If eligible,
    Total Deductions $198.00
    the county will award you a $20.01 SUAS cash
    payment. This is a one-time per year payment and if
    Preliminary Adjusted Income $856.15
    eligible it will be put into your cash Electronic Benefit
    Housing Expenses $428.08
    Transfer (EBT) account. If you do not have a cash EBT
    Utility Expenses $596.00
    account, one will be set up for you on your CalFresh
    Adjusted Net Income $688.00
    EBT card. You will not have to do anything to get a new
    card, but you can use it to cover expenses not
    CalFresh Allotment $78.00
    Less Overissuance -$0.00
    Rules: These rules apply; you may review them at your welfare office:
    MPP 63-300.4, 63-504.1, 63-504.22, 63-504.6 Total CalFresh Allotment =$78.00

    CF 377.1 (05/20) Page 1 of 2

    0000000487675790
    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:
    Neighborhood Legal Services of Los Angeles County (NLSLA)
    (800) 433-6251

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


    0000000487675790
    STATE OF CALIFORNIA
    COUNTY OF LOS ANGELES
    NOTICE OF ACTION HEALTH AND WELFARE AGENCY
    CALIFORNIA DEPARTMENT OF SOCIAL
    Continuation Page SERVICES

    NOTICE DATE: May 03, 2024


    CASE NAME: CHARLETTE D CARPENTER
    CASE NUMBER: B0PWV23
    WORKER NAME: Customer Service
    WORKER ID: 19DP67146L
    TELEPHONE NUMBER: (866) 613-3777
    CUSTOMER ID: 1850508341

    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.

    CF 377.1 (05/20) Page 2 of 2

    0000000487675790
    0000000487675790

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