Form Na 1261b - Notice Of Action - Form And Instructions - For Kinship-Guardians Only

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NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FORM AND INSTRUCTIONS -
(4) Notice Date:
(5) Case Name:
FOR KINSHIP-GUARDIANS ONLY
(6) Case Worker Number:
(7) Case Worker Name:
(8) Case Number:
(9) Telephone:
(10) Address
(1) Name:
:
(2) Address:
(3) City, State Zip:
FOR KINSHIP-GUARDIANSHIP ASSISTANCE PAYMENT
(KIN-GAP) GUARDIANS ONLY:
This is to inform you that you were overpaid Kin-GAP benefits
If you fail to make a one-time payment of the total amount or
enter into a written payment agreement, you may be subject to
(11)for ________________________________________________
a reduction in the payment for the child/youth identified at the
(NAME OF CHILD)
top of this form or civil judgment.
(12) for the month(s)______________________________________
(13) Total amount you received: $ ___________________________
If you have any questions regarding the over payment
computation or repayment arrangements, please contact the
(14) Total amount you should have received: $_________________
case worker at the top of this form.
(15) Total amount of Overpayment: $_________________________
(19) Insert overpayment calculations and substantiation of time
(16) Date of Discovery: _____________________Collections is
periods by month as required in regulation. See MPP Section
permitted if demand is made within one year of discovery.
45-305. Attach a page if additional space is needed.
(17) You are required to repay the overpayment amount of
$ _____________.
(18) Reason for the overpayment:
I
(A) From _________________________ (date) Support was
not provided to the child/youth and you failed to report to your
county social worker and you
received payments for him/her that you were not entitled to.
I
(B) Other: __________________________________________
By law we can collect Kin-GAP overpayments if the Kin-GAP
Guardian caused or contributed to the overpayment. We cannot
require you to repay the overpayment if you meet an exception.
Exceptions to repayment are:
The overpayment was caused by county administrative error,
G
or
Both the county and the foster care provider did not know of
G
or contribute to the cause of the overpayment.
The minor’s absence was temporary and the funds were
G
used to maintain the home for their return or used to support
their needs.
If you disagree with the reason for overpayment or the amount
of the overpayment, or if you think the exception applies, you
may request a hearing. Please see following pages for hearing
instructions.
If you agree with the reason for the over payment and the
overpayment amount, you must do one of the following within 90
calendar days from the day the county gave or mailed you this
notice:
1) Make a one-time payment of the total amount;
Please pay by check or money order, made payable to:
Send to:
2) Sign a written repayment agreement. You must contact the
worker at the top of this form discuss the terms of a written
Relevant Law: Welfare and Institutions Code sections 11466.24,
payment agreement.
Manual of Policies and Procedures (MPP) sections 22-009,45-304,
45-305, and 45-306.
NA 1261B (1/16) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE____ OF___

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