HSA Main Office STATE OF CALIFORNIA
COUNTY OF SAN JOAQUIN HEALTH AND WELFARE AGENCY
PO BOX 201056
CALIFORNIA DEPARTMENT OF SOCIAL
STOCKTON, CA 95201-3006
SERVICES
NOTICE DATE: March 08, 2024
CASE NAME: SHURJEEL RAJA
CASE NUMBER: 2295485
WORKER NAME: N Nguyen
WORKER ID: 39LS011B04
TELEPHONE NUMBER: (209) 468-0179
CUSTOMER ID: 4024932408
CALFRESH NOTICE OF
CHANGE FOR SEMI-ANNUAL
REPORTING HOUSEHOLD
SHURJEEL RAJA
2843 HEDO PL
STOCKTON, CA 95212-2872
Questions? Ask your worker.
As of 04/01/2024, the County is changing your CalFresh State Hearing: If you think this action is wrong, you
benefits from $291.00 to $23.00. 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
The deductions you are allowed for housing or utilities
have changed.
When your housing or utility expenses change the Report Month 04/2024
deduction also changes.
Household Size 1
Your CalFresh household size is 1. Your IRT is
$1,580.00. Total Countable Earned Income $0.00
Adjusted Countable Earned Income $0.00
Total Countable Unearned Income $1,239.52
Net Countable Income $1,239.52
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 $1,041.52
Housing Expenses $520.76
Utility Expenses $596.00
Adjusted Net Income $966.00
CalFresh Allotment $23.00
Less Overissuance -$0.00
Rules: These rules apply; you may review them at your local welfare
office: 63-504.35; 63-502.3, 63-502.35, 63-504.35, 63-505, 603-503.3 Total CalFresh Allotment =$23.00
CF 377.4 SAR (6/13) Page 1 of 1
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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: Human Services Agency
“Submit Appeal without Account” to file without an account 333 E WASHINGTON ST
OR PO BOX 201056
STOCKTON, CA 95201
• 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: SHDCSU@DSS.ca.gov
HEARING REQUEST
1. My hearing issue involves (benefit program)
and SAN JOAQUIN 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:
California Rural Legal Assistance
145 E WEBER AVE
STOCKTON, CA 95202
(209) 946-0605
NA Back 9 (5/22) Required Form - No Substitute Permitted
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