Form Soc 807a - Cash Assistance Program For Immigrants (Capi) - Request For Waiver Of Overpayment Recovery - Without Fault

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
REQUEST FOR WAIVER OF OVERPAYMENT RECOVERY - WITHOUT FAULT
NAME OF OVERPAID PERSON
SOCIAL SECURITY NUMBER
1.
Do you believe the overpayment was not your fault and you cannot afford to pay the
money back and/or it is unfair for some other reason? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2.A.
Why did you think you were due the overpaid money?_________________________________________________________
____________________________________________________________________________________________________
B.
Why do you think you were not at fault in causing the overpayment or accepting the money?___________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3.A.
Did you tell us about the change or event that made you overpaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If No, why didn’t you tell us?______________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
B.
If Yes, how, when, and where did you tell us? If you told us by phone or in person, who did you talk with and what was said?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
C.
If you did not hear from us after your report, and/or your benefits did not change,
did you contact us again? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
4.
Have you been overpaid on CAPI before? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, why were you overpaid before? If the reasons for your previous and current overpayments are
similar, explain what you did to try to prevent the present overpayment.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5.A.
Do you have any of the overpaid checks or money in your possession (including in a savings
or any other type of account)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, return the amount in your possession to your county welfare department.
B.
Did you have any of the overpaid checks, or their proceeds, in your possession at the time
you received the overpayment notice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, explain why you believe you should not have to return this amount.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6.
Are you now receiving CAPI, SSI, or other public assistance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, what type?
_____________________________________________________________________
I declare under penalty of perjury under the laws of the State of California that the answers I have given are correct and true to
the best of my knowledge.
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE
DATE
RESIDENCE ADDRESS:
PHONE NUMBER
CITY
STATE
ZIP CODE
SOC 807A (7/00)

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