036 Pomona STATE OF CALIFORNIA

COUNTY OF LOS ANGELES HEALTH AND WELFARE AGENCY

2040 W HOLT AVE
CALIFORNIA DEPARTMENT OF SOCIAL
POMONA, CA 91768-3307
SERVICES

NOTICE DATE: December 12, 2021

CASE NAME: ALISHA Reason
CASE NUMBER: B0FWY62
WORKER NAME: Customer Service
WORKER ID: 19DP364P02
TELEPHONE NUMBER: (866) 613-3777
CUSTOMER ID: 1850511620

CALFRESH NOTICE OF
CHANGE FOR SEMI-ANNUAL
REPORTING HOUSEHOLD
ALISHA M REASON
1440 CAMPER VIEW RD
space #G27
SAN DIMAS, CA 91773-3924

Questions? Ask your worker.

As of 01/01/2022, the County is changing your CalFresh State Hearing: If you think this action is wrong, you
benefits from $254.00 to $246.00. can ask for a hearing. The back page tells you how.
Your benefits may not be changed if you ask for a
Here's Why: hearing before this action takes place.
When your income changes, your CalFresh benefits
amount also changes.
CalFresh Budget
Your CalFresh household size is 2. Your IRT is
$1,888.00.
Report Month 01/2022

Household Size 2

Total Countable Earned Income $0.00

Adjusted Countable Earned Income $0.00
Total Countable Unearned Income $1,625.14
Net Countable Income $1,625.14

Standard Deduction $177.00

Dependent Care $0.00
Homeless Shelter Deduction $0.00
Excess Medical Expense for Aged/Disabled $0.00
Total Deductions $177.00

Preliminary Adjusted Income $1,448.14

Housing Expenses $724.07
Utility Expenses $487.00
Adjusted Net Income $665.00

CalFresh Allotment $259.00

Less Overissuance -$13.00
Rules: These rules apply; you may review them at your local welfare
office: 63-504.35 Total CalFresh Allotment =$246.00

CF 377.4 SAR (6/13) Page 1 of 1

817679559
 YOUR HEARING RIGHTS TO ASK FOR A HEARING:
You have the right to ask for a hearing if you disagree with any • Fill out this page.
county action. You have only 90 days to ask for a hearing. The 90 • Make a copy of the front and back of this page for your
days started the day after the county gave or mailed you this records. If you ask, your worker will get you a copy of this
notice. If you have good cause as to why you were not able to file page.
for a hearing within the 90 days, you may still file for a hearing. If • Send or take this page to:
you provide good cause, a hearing may still be scheduled. Appeals & Hearing Section
P.O. Box 18890
If you ask for a hearing before an action on Cash Aid, Los Angeles, CA 90018
Medi-Cal, CalFresh, or Child Care takes place:
• Your Cash Aid or Medi-Cal will stay the same while you wait for a
hearing. OR
• Your Child Care Services may stay the same while you wait for a • Call toll free: 1-800-952-5253 or for hearing or speech impaired who
hearing. use TDD, 1-800-952-8349.
• Your CalFresh will stay the same until the hearing or the end of your
certification period, whichever is earlier. To Get Help: You can ask about your hearing rights or for a legal
If the hearing decision says we are right, you will owe us for any aid referral at the toll-free state phone numbers listed above. You
extra Cash Aid, CalFresh or Child Care Services you got. To let us may get free legal help at your local legal aid or welfare rights office.
lower or stop your benefits before the hearing check below:
Neighborhood Legal Services of Los Angeles County (NLSLA)
Yes, lower or stop: Cash Aid CalFresh Child Care (800) 433-6251
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 you do not want to go to the hearing alone, you can bring a
If we told you your other supportive services payments will stop, you will friend or someone with you.
not get any more payments, even if you go to your activity.
HEARING REQUEST
If we told you we will pay your other supportive services, they will be I want a hearing due to an action by the Welfare Department of
paid in the amount and in the way we told you in this notice. LOS ANGELES County about my:
Cash Aid CalFresh Medi-Cal
• To get those supportive services, you must go to the activity the
county told you to attend. Other (List)
• If the amount of supportive services the county pays while you Here's Why:
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 If you need more space, check here and add a page.
approved activity. I need the state to provide me with an interpreter at no cost to
OTHER INFORMATION me. (A relative or friend cannot interpret for you at the
hearing.)
Medi-Cal Managed Care Plan Members: This action on this notice My language or dialect is:
may stop you from getting services from your managed care health NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
plan. You may wish to contact your health plan membership services if
BIRTH DATE PHONE NUMBER
you have questions.
STREET ADDRESS
Child and/or Medical Support: The local child support agency will
CITY STATE ZIP CODE
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 SIGNATURE DATE
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. NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER

Family Planning: Your welfare office will give you information when I want the person named below to represent me at this
you ask for it. 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.)
Hearing File: If you ask for a hearing, the State Hearing Division will NAME PHONE NUMBER
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 STREET ADDRESS
days before the hearing. The state may give you hearing file to the
CITY STATE ZIP CODE
Welfare Department and the U.S. Departments of Health and Human
Services and Agriculture. (W&I Code Sections 10850 and 10950.)

NA BACK 9 (REPLACES NA BACK 8 AND EP 5)(REVISED 4/2013) - REQUIRED FORM - NO SUBSTITUTE PERMITTED