Form Na 1269 - Notice Of Action - Approval
Download a blank fillable Form Na 1269 - Notice Of Action - Approval in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Na 1269 - Notice Of Action - Approval with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2NOTICE OF ACTION -
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPROVAL
Notice Date :
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. The back of this page tells how. Your
benefits may not be changed if you ask for a hearing
before this action takes place.
The County has approved your cash aid. The cash aid payment for
your first month of aid is $______________.
Your first day of cash aid is ____________________.
MM/DD/CCYY
The cash aid payment for your first month of aid is only for a part of a
month. It is for the time from your first day of cash aid, shown above,
through the end of the month. If nothing changes, your ongoing cash
aid amount will be $______________.
Rules: These rules apply. You may review them at your county
welfare office:
WIC 11253, AB 12 (Chapter 559, Statutes of
2010).
Page 1 of ____
NA 1269 (11/11) APPROVE NON-MINOR DEPENDENT - REQUIRED FORM - SUBSTITUTE PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Na 403a - Notice Of Action - Approval, Change Or Discontinued For Kinship - Guardians Only
Legal
Related Categories
Parent category: Legal