COUNTY OF LOS ANGELES

EXPOSITION PARK
3833 VERMONT AVE
LOS ANGELES,CA 90037
UNITED STATES Date: 12/12/2023
Case Name: ANTONIO WHITE
Case Number: B1YZW35
Worker Name:
Worker ID:
Worker Phone Number:
Customer ID:

I wish to withdraw my application dated for:

CalWORKs/Refugee Cash Assistance

CalFresh

Medi-Cal/State-Run CMSP

CAPI

GA/GR

Please answer the following questions:

a) Did you decide to drop this application? ............................................... Yes No

b) Did anyone from the County tell you to drop this application? .............. Yes No

I understand that I may reapply at any time. I also understand that by withdrawing my application, I will have no
appeal rights.

YOU WILL NOT GET A HEARING IF YOU SIGN THIS FORM. THE COUNTY WILL SEND YOU A LETTER TO
CONFIRM YOUR APPLICATION WITHDRAWAL.
SIGNATURE OF APPLICANT DATE

SIGNATURE OF APPLICANT DATE

COUNTY REPRESENTATIVE DATE

CW 89 (02/03) RECOMMENDED FORM