Form Na 1263 - Notice Of Action - Overissuance Budget Worksheet

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NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date
_________________________________________________________________________
Case
Name
_________________________________________________________________________
Number
_________________________________________________________________________
Overissuance Month and Year
Part 1 - GROSS INCOME ELIGIBILITY
A. NONEXEMPT GROSS UNEARNED INCOME
$
$
$
$
1.
Cash Aid
$
$
$
$
2.
Social Security, UIB, DIB, Pensions
$
$
$
$
3.
Child/Spousal Support
$
$
$
4.
Scholarships, Grants, Loans
$
$
$
$
5.
Other
$
$
6.
Unreported Gross Unearned Income
$
$
$
$
$
7.
Gross Unearned Income (A1+A2+A3+A4+A5+A6)
$
$
8.
Less Child Support Paid (enter remainder in B7)
$
$
$
$
$
9.
Total Gross Unearned Income (A7 - A8)
$
$
$
B. NONEXEMPT GROSS EARNED INCOME
$
$
$
$
1.
Gross Salary, Wages
$
2.
Self-Employment
$
$
$
$
$
$
$
3.
Training Allowance
$
$
$
$
4.
Gross Earned Income (B1+B2+B3)
$
$
$
5.
Unreported Gross Earned Income
$
6.
Adjusted Gross Earned Income (B4+B5)
(including unreported income)
$
$
$
$
7.
Less Remainder of Child Support Paid
$
$
(If not fully used in Section A)
$
$
8.
Total Gross Earned Income (B6-B7)
$
(If negative amount, enter zero)
$
$
$
C. GROSS INCOME TEST
Not figured for households with an elderly/disabled
member. (MPP 63-503.323)
1.
Household size
2.
Maximum Gross Income Allowed from table
$
$
$
$
$
3.
Total Countable Gross Monthly Income (A9+B8)
$
$
$
4.
Gross Income eligible? (Is C3 less than or equal
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
Yes
No
NA
Yes
No
NA
to C2?)
Yes
No
NA
Yes
No
NA
D. GROSS INCOME OVERISSUANCE (IF C4 IS NO)
1.
Amount Previously Issued
$
$
$
$
$
2.
Correct Benefit
$
$
$
$
3.
Total CalFresh Overissuance (D1-D2)
$
$
$
$
$
$
$
4.
Minus Lost Benefits Not Restored
$
$
$
$
5.
Minus Payment Received
6.
Amount of Overissuance to be Collected
$
$
$
(D3-D4-D5)
$
$
$
$
$
7.
Minus Workfare Offset
$
8.
Amount of Overissuance to be Collected (D6-D7)
$
$
$
PART 2 - NET INCOME ELIGIBILITY
(This section computes only if C4 is Yes.)
$
$
$
$
E.
NONEXEMPT GROSS UNEARNED INCOME (A9)
F.
NONEXEMPT GROSS EARNED INCOME
$
$
$
$
1.
Gross Earned Income(Not Including unreported income)(B4)
$
$
$
$
2.
Adjusted Gross Earned Income (80% of F1)
$
$
$
$
3.
Unreported Gross Earned Income
$
4.
Total Countable Earned Income (F2+F3)
$
$
$
5.
Less remainder of Child Support Paid (B7) (If not
$
$
$
$
fully used in Section A)
6.
Total Gross Earned Income (F4 - F5)
$
$
$
$
(If negative amount, enter zero)
$
$
$
$
G. TOTAL NONEXEMPT GROSS INCOME (E+F6)
H. STANDARD/DEPENDENT CARE/HOMELESS
SHELTER/DEDUCTION
$
$
$
$
1.
Standard Deduction
2.
Excess Medical Expenses (Only compute
excess medical expenses for households with
$
$
$
$
elderly/disabled members.)
$
$
$
$
3.
Dependent Care (100% of costs)
$
$
$
$
4.
Homeless Shelter Deduction
$
$
$
$
5.
Total Deductions (H1+H2+H3+H4)
$
$
$
$
6.
Total Adjusted Income (G-H5)
NA 1263 (8/11) CONTINUATION PAGE
Page _________ of ________

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