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

San Bernardino County COUNTY OF SAN BERNARDINO

265 E 4TH STREET
SAN BERNARDINO, CA 92415-0039
Date: 06/18/2025
Case Name: Pamela Smith
Case Number: 1417426
Worker Name: CUSTOMER REP
Worker ID:
NOTICE OF ACTION Worker Phone Number: (877) 410-8829

PAMELA M SMITH
1175 W FOOTHILL BLVD
RIALTO, CA 92376-4642

Questions? Ask Your Worker

State Hearing: If you think this action is wrong, you can
ask for a hearing. The back of this page tells how.

On 06/18/2025 , the County stopped access to your

cash aid Electronic Benefit Transfer- EBT

HERE'S WHY:

You have not used your cash aid EBT card for 180 days.

Call your County Worker to access your cash aid EBT.

If you have lost your card call the toll free number
(1-877-328-9677).
If you need help using EBT, call your County Worker.

This notice:
• does not change your eligibility to get cash aid;
• does not change your responsibility to report
changes that affect your eligibility;
• does not change the unused cash aid benefit in your
EBT account;
• does not change your CalFresh or Medi-Cal
benefits. If these benefits change, you will get a
separate notice.

M16 120B (06/2011)

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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: APPEALS UNIT
“Submit Appeal without Account” to file without an account San Bernardino
OR PO BOX 1409
SAN BERNARDINO, CA 92402-1409
• 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 Bernardino 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: 15428 Civic Drive Ste 175, Victorville, CA 92392
High Desert (760) 241-7073 Phone Numbers: Intake Line (888) 245-4257 Senior Line (800) 977-4257
West End (909) 980-0982
San Bernardino Area (909) 884-8615 Inland Counties Legal Services
CCWRO: (916) 736-0616 3500 Porsche Way Suite 200, Ontario, CA 91764

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

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