Form Na 1280 - Notice Of Action - Discontnue - Approved Relative Caregiver (Arc) Payment
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1
2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION - DISCONTINUE
APPROVED RELATIVE CAREGIVER
Notice Date:
(ARC) PAYMENT
Case Name:
Number:
Worker Name:
Number:
Telephone:
Address:
(ADDRESSEE)
Questions? Ask your Worker.
State Hearing: If you think this action is wrong, you can ask for a
hearing. Your benefits may not be changed if you ask for a
hearing before this action takes place. If you and the county
disagree or if you have not heard back from your worker, do not
wait to ask for a hearing. You must ask for the hearing before a
certain number of days. See the back of this notice for more
information and to find out how to ask for a hearing.
For Approved Relative Caregivers participating in the
Approved Relative Caregiver Funding Option Program
(ARC Program):
As of ___________, the County is stopping your cash aid
MM/DD/YYYY
for _______________________________ under the ARC Program.
NAME OF CHILD
Here’s why:
You are no longer eligible for cash aid under the ARC Program for
one or more of the following reasons:
I
The child is no longer placed with you.
I
Your home is no longer approved, and you received a Notice of
Action—Denial of Home Assessment/Approval (NA 1271) from
the County explaining why.
I
The child is no longer under the jurisdiction of the California
juvenile court.
I
You no longer live in California.
I
The child no longer lives in California.
I
The child is not eligible because of age.
I
Other
____________________________________________________.
Rules: These rules apply. You may review them at your county
welfare office: Welfare and Institutions Code section 11461.3,
Senate Bill 855 (Chapter 29, Statutes of 2014); Section 58 of
Chapter 20 of the Statutes of 2015; All County Information Notice
I-42-14; All County Letters 14-89, 15-20, 15-20E, 15-83, and 16-92;
and County Fiscal Letters 14-15-45, 14-15-52, 14-15-58, 15-16-07,
and 15-16-24.
Page 1 of ______
NA 1280 (11/16)
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