1440 Harrison Service Center STATE OF CALIFORNIA

COUNTY OF SAN FRANCISCO HEALTH AND WELFARE AGENCY

PO BOX 7988
CALIFORNIA DEPARTMENT OF SOCIAL
SAN FRANCISCO, CA 94120-7988
SERVICES

NOTICE DATE: November 15, 2024

CASE NAME: DEVIN ANDERSON
CASE NUMBER: BA94153
WORKER NAME: Bank SFBN
WORKER ID: 38LS0GGQ09
TELEPHONE NUMBER: (855) 355-5757
CUSTOMER ID: 4045230271
CALFRESH NOTICE OF
APPROVAL

Devin Anderson
1036 MISSION ST
APT 307
SAN FRANCISCO, CA 94103-2904

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 11/2024. hearing before this action takes place.
Your benefit amount per month for the rest of your
certification period will be $138.00 from 12/01/2024
through 10/31/2027.
CalFresh Budget
For CalFresh, your family size is 1. Your IRT is
$1,632.00. Report Month 11/2024
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 $0.00
Adjusted Countable Earned Income $0.00
The amounts used to figure your CalFresh are shown Total Countable Unearned Income $1,207.00
on this notice. If your case contains a disqualified Net Countable Income $1,207.00
person(s) and that/those person(s) has/have income, all
of their income is used to compute your CalFresh Standard Deduction $204.00
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 $204.00
the county will award you a $20.01 SUAS cash
payment. This is a one-time per year payment and if
Preliminary Adjusted Income $1,003.00
eligible it will be put into your cash Electronic Benefit
Housing Expenses $501.50
Transfer (EBT) account. If you do not have a cash EBT
Utility Expenses $645.00
account, one will be set up for you on your CalFresh
Adjusted Net Income $512.00
EBT card. You will not have to do anything to get a new
card, but you can use it to cover expenses not

Rules: These rules apply; you may review them at your welfare office: CalFresh Allotment $78.00
MPP §§63-300.4, 63-504.1, 63-504.22, 63-504.6 Less Overissuance -$0.00
Total CalFresh Allotment =$78.00

CF 377.1 (05/20) Page 1 of 2

0000000553193153
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 Unit, Department of Human
“Submit Appeal without Account” to file without an account Services
OR 1650 Mission St
5th Floor
• Call toll free (800) 743-8525 (or TDD (800) 952-8349 ) OR San Francisco, CA 94103
(800) 952-8349 / Fax: (833) 281-0905
• Fax fill out this page/fax to (833) 281-0905 OR Toll Free: (800) 743-8525
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 SAN FRANCISCO 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:
Appeals Unit, Department of Human Services
PO BOX 7988, San Francisco, CA 94120
1-800-952-5253
Toll Free: 1-800-952-5253
BAY AREA LEGAL AID
1800 Market St 3rd Floor, San Francisco, CA 94102
415-982-1300 / Fax: 415-982-4243

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

0000000553193153
 STATE OF CALIFORNIA
COUNTY OF SAN FRANCISCO
NOTICE OF ACTION HEALTH AND WELFARE AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL
Continuation Page SERVICES

NOTICE DATE: November 15, 2024

CASE NAME: DEVIN ANDERSON
CASE NUMBER: BA94153
WORKER NAME: Bank SFBN
WORKER ID: 38LS0GGQ09
TELEPHONE NUMBER: (855) 355-5757
CUSTOMER ID: 4045230271

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

0000000553193153
0000000553193153