Banning Self Sufficiency STATE OF CALIFORNIA

COUNTY OF RIVERSIDE HEALTH AND WELFARE AGENCY

63 S 4TH ST
CALIFORNIA DEPARTMENT OF SOCIAL
BANNING, CA 92220-4861
SERVICES

NOTICE DATE: January 30, 2025

CASE NAME: Demitrius Leonard
CASE NUMBER: 2738073
WORKER NAME: Robert Willett III
WORKER ID: 33LS228309
TELEPHONE NUMBER: (951) 922-7223
CUSTOMER ID:
CALFRESH NOTICE OF
APPROVAL

Demitrius W Leonard
15050 CHOLLA RD
WHITEWATER, CA 92282-2913

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: $23.00 for 02/2025. hearing before this action takes place.
Your benefit amount per month for the rest of your
certification period will be $23.00 from 03/01/2025
through 01/31/2026.
CalFresh Budget
For CalFresh, your family size is 1. Your IRT is N/A.
Report Month 02/2025
IF YOU ALSO APPLIED FOR CASH AID, and it has
not yet been approved, your CalFresh benefits may be
lowered or stopped without another notice if your cash Household Size 1
aid is approved.
Total Countable Earned Income $0.00
The amounts used to figure your CalFresh are shown Adjusted Countable Earned Income $0.00
on this notice. If your case contains a disqualified Total Countable Unearned Income $1,707.60
person(s) and that/those person(s) has/have income, all Net Countable Income $1,707.60
of their income is used to compute your CalFresh
allotment. Standard Deduction $204.00
Dependent Care $0.00
Your CalFresh household may be eligible to a State
Homeless Shelter Deduction $0.00
Utility Assistance Subsidy (SUAS) payment. If eligible,
Excess Medical Expense for Aged/Disabled $0.00
the county will award you a $20.01 SUAS cash
Total Deductions $204.00
payment. This is a one-time per year payment and if
eligible it will be put into your cash Electronic Benefit
Preliminary Adjusted Income $1,503.60
Transfer (EBT) account. If you do not have a cash EBT
Housing Expenses $751.80
account, one will be set up for you on your CalFresh
Utility Expenses $645.00
EBT card. You will not have to do anything to get a new
Adjusted Net Income $1,504.00
card, but you can use it to cover expenses not
otherwise covered by CalFresh. This payment allows

Rules: These rules apply; you may review them at your welfare office: CalFresh Allotment $23.00
MPP §§63-300.4, 63-504.1, 63-504.22, 63-504.6 Less Overissuance -$0.00
Total CalFresh Allotment =$23.00

CF 377.1 (05/20) Page 1 of 2

0000000577609378
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: Administrative Hearings Unit
“Submit Appeal without Account” to file without an account Department of Public Social Services
OR 7894 Mission Grove Pkwy S. Ste100
RIVERSIDE, CA 92508
• 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 RIVERSIDE 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:
Inland Counties Legal Services, Inc.
1040 Iowa Avenue
Ste 109
RIVERSIDE, CA 92507
(951) 368-2555 / Fax: (951) 368-2550
Toll Free: (888) 245-4257

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

0000000577609378
 STATE OF CALIFORNIA
COUNTY OF RIVERSIDE
NOTICE OF ACTION HEALTH AND WELFARE AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL
Continuation Page SERVICES

NOTICE DATE: January 30, 2025

CASE NAME: Demitrius Leonard
CASE NUMBER: 2738073
WORKER NAME: Robert Willett III
WORKER ID: 33LS228309
TELEPHONE NUMBER: (951) 922-7223
CUSTOMER ID:

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.
Rules: These rules apply; you may review them at your
welfare office:
MPP Sections §§63-300.4, 63-504.1, 63-504.22,
63-504.6

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