STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Butte - CEC-O COUNTY OF BUTTE

PO BOX 1649
OROVILLE, CA 95965-1649
Date: 01/25/2024
Case Name: Sara Lopez
Case Number: 2063604
Worker Name: Sixty One Unit
Worker ID: 04LS026100
Notice Of Action Worker Phone Number: (877) 410-8803

Butte - CEC-O
SARA B LOPEZ
PO BOX 1649
PO BOX 387
OROVILLE, CA 95965-1649
FOREST RANCH, CA 95942-0387

Questions? Ask your Worker or call the number above.

As of 01/31/2024 , the County is stopping your:
State Hearing: If you think this action is wrong, you can ask for
Cash Aid Diaper Assistance Payments a hearing. The back of this page tells you how. Your benefits
CalFresh may not be changed if you ask for a hearing before this action
takes place.
Here's why:

The semi-annual report (SAR 7) that we got from you this The information you give us may change or stop your cash aid and//
reporting period is not complete. or CalFresh benefits.
To continue to get cash aid and/or CalFresh benefits you If you turn in a complete SAR 7 anytime next month that shows
you are eligible for cash aid and/or CalFresh, your benefits will
must return a complete SAR 7.
start from the date you turn in the form.
If your benefits are discontinued because you fail to turn in a
A SAR 7 is complete when you have answered all of the complete SAR 7, you will not receive Transitional CalFresh
questions and have attached required proof. If you are benefits.
having problems getting the proof, call the County and we If you have any questions about Transitional CalFresh, please
can help you try to get it. contact your county office.
Medi-Cal: This notice DOES NOT change or stop Medi-Cal
The county must get your complete report no later than Benefits. If there is a change in your Medi-Cal benefits, you will get
the first working day of next month. another notice.
Keep using your plastic Benefits Identification Card(s).
You must send or bring in the following information:
Income Information Missing You and your family may still continue to get Medi-
Question 9 states to report income for the report month of 12/2023. You Cal if your cash aid stops and:
provided payslips for Benjamin for Aug., Sept., Oct., & Nov. 2023. We need
proof of income for the report month of 12/2023. If this income has ended;
• You have earnings from a job, a business you started or if you
received a pay raise.
provide proof showing end date.
• You have started to receive or had an increase in child/spousal
We show Sara has self employment income from house cleaning. Please support payments.
provide proof of this income for the report month of 12/2023; if this income If you need help completing the SAR 7, contact the County and ask
has ended; provide proof showing end date. Please provide proof of for help.
unemployment received for the report month of 12/2023 for Sara. You
provided 7/2023. Return the required proof in the enclosed SASE or upload Toll Free (877) 410-8803 .
them to benefitscal,com.

Thank you.

Rules: These rules apply. You may review them at your welfare office:
Cash Aid: MPP Sections 40-105.1, 40-181.22; CalFresh: MPP Sections
63-103n(2), 63-508.6.

NA 960Y SAR (10/14) STOP AID: REPORT INCOMPLETE

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 YOUR HEARING RIGHTS TO ASK FOR A HEARING:
You have the right to ask for a hearing if you disagree • Fill out this page.
with any county action. You have only 90 days to ask for • Make a copy of the front and back of this page for your records.
a hearing. The 90 days started the day after the county If you ask, your worker will get you a copy of this page.
gave or mailed you this notice. If you have good cause as • Send or take this page to:
to why you were not able to file for a hearing within the 90 Department of Employment and Social Services
days, you may still file for a hearing. If you provide good 202 MIRA LOMA DR
PO BOX 1649
cause, a hearing may still be scheduled. OROVILLE, CA 95965
If you ask for a hearing before an action on Cash Aid, (530) 538-5127 / Fax: (530) 534-5745
Medi-Cal, CalFresh, or Child Care takes place:
• Your Cash Aid or Medi-Cal will stay the same while you wait OR
• Call toll free: 1-800-952-5253 or for hearing or speech impaired
for a hearing.
who use TDD, 1-800-952-8349.
• Your Child Care Services may stay the same while you wait
for a hearing. To Get Help: You can ask about your hearing rights or for a
• Your CalFresh will stay the same until the hearing or the end of legal aid referral at the toll-free state phone numbers listed
your certification period, whichever is earlier. 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 Legal Services of Northern California
541 NORMAL ST
any extra Cash Aid, CalFresh or Child Care Services you
CHICO, CA 95928
got. To let us lower or stop your benefits before the hearing (800) 345-9491 / Fax: (530) 345-6913
check below: Toll Free: (800) 345-9491
Yes, lower or stop: Cash Aid CalFresh
Child Care If you do not want to go to the hearing alone, you can bring
While You Wait for a Hearing Decision for: a friend or someone with you.
Welfare to Work: HEARING REQUEST
You do not have to take part in the activities. I want a hearing due to an action by the Welfare Department of
Butte County about my:
You may receive child care payments for employment and for
activities approved by the county before this notice. Cash Aid CalFresh Medi-Cal
If we told you your other supportive services payments will stop, Other (List)
you will not get any more payments, even if you go to your Here's Why:
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 If you need more space, check here and add a page.
participate, you can stop going to the activity. 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
Cal-Learn: hearing.)
• You cannot participate in the Cal-Learn Program if we told you My language or dialect is:
we cannot serve you. NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
• We will only pay for Cal-Learn supportive services for an
BIRTH DATE PHONE NUMBER
approved activity.
STREET ADDRESS
OTHER INFORMATION
Medi-Cal Managed Care Plan Members: This action on this notice may stop CITY STATE ZIP CODE
you from getting services from your managed care health plan. You may wish to
contact your health plan membership services if you have questions. SIGNATURE DATE
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 NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER
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 I want the person named below to represent me at this
money collected that is owed to the county. hearing. I give my permission for this person to see my
Family Planning: Your welfare office will give you information when you ask
records or go to the hearing for me. (This person can be
for it.
a friend or relative but cannot interpret for you.)
NAME PHONE NUMBER
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
STREET ADDRESS
the county's written position on your case at least two days before the hearing.
The state may give you hearing file to the Welfare Department and the U.S. CITY STATE ZIP CODE
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

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