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    Denial

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    Denial

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    Denial

    Uploaded by

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    of 2

    027 South Central STATE OF CALIFORNIA

    COUNTY OF LOS ANGELES HEALTH AND WELFARE AGENCY


    10728 S CENTRAL AVE
    CALIFORNIA DEPARTMENT OF SOCIAL
    LOS ANGELES, CA 90059-1020
    SERVICES

    NOTICE DATE: September 11, 2024


    CASE NAME: RAFAEL HUERTA GALLARDO
    CASE NUMBER: L497B96
    WORKER NAME: Judith Montano-Rico
    WORKER ID: 19DP27RC08
    TELEPHONE NUMBER: (866) 613-3777
    CUSTOMER ID: 4004051762

    NOTICE OF ACTION
    CALWORKS DENIAL
    RAFAEL A HUERTA GALLARDO
    16506 KNOLL STONE CIR
    CERRITOS, CA 90703-2007

    Questions? Ask your worker.

    The County has denied your application for cash aid State Hearing: If you think this action is wrong, you
    dated 08/12/2024. 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.
    To get aid, there must be at least one of the following
    persons living in the home:
    An eligible child, or
    A caretaker relative of an SSI/SSP child, or
    A caretaker relative of a dependent foster care child, or
    A caretaker relative of a Kin-GAP child, or
    A pregnant teen under age 19 without a high school
    diploma
    or its equivalent, or
    A pregnant person, or
    A parent of a child who is sanctioned by the CalWORKs
    Welfare-to-Work Program.

    Rules: These rules apply; you may review them at your welfare office:
    82-820.2

    M82-820A (09/21) Page 1 of 1

    0000000531805877
    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:
    Legal Aid Foundation of Los Angeles (LAFLA)
    (800) 399-4529

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


    0000000531805877

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