Form Na 1263 - Notice Of Action - Overissuance Budget Worksheet Page 2
Download a blank fillable Form Na 1263 - Notice Of Action - Overissuance Budget Worksheet 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 1263 - Notice Of Action - Overissuance Budget Worksheet 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
2Overissuance Month and Year
I.
SHELTER DEDUCTIONS
$
$
$
$
1.
Total Housing Cost
$
$
$
2.
Total Utility Allowance
$
3.
Total Shelter Costs (I1+I2)
$
$
$
$
4.
Allowable Shelter Costs (50% of H6)
$
$
$
$
5.
Excess Shelter Costs (I3-I4)
$
$
$
$
6.
Maximum Allowance for Shelter
(Enter amount shown on I5 for households
$
$
$
$
with an elderly/disabled member)
7.
Allowable Shelter Deduction (Lesser of I5 or I6)
(Enter amount shown on I5 for households with an
$
$
$
$
elderly/disabled member.)
J.
NET COUNTABLE MONTHLY INCOME (H6-I7)
$
$
$
$
K. NET INCOME TEST
1.
Household Size
$
$
$
2.
Maximum Net Income allowable from table
$
3.
Net Income eligible?
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
Yes
No
NA
(Is J less than or equal to K2?)
Yes
No
NA
Yes
No
NA
Yes
No
NA
L.
NET INCOME OVERISSUANCE
$
$
$
1.
Amount Previously Issued/Authorized
$
2.
Correct Benefit
$
$
$
$
3.
Total CalFresh Overissuance (L1-L2)
$
$
$
$
4.
Minus Lost Benefits Not Restored
$
$
$
$
5.
Minus payment Received
$
$
$
$
6.
Amount of Overissuance to be Collected
$
$
$
(L3-L4-L5)
$
$
$
$
7.
Minus Workfare Offset
$
8.
Amount of Overissuance to be Collected
$
$
$
$
(L6-L7)
PART 3 - RESOURCE ELIGIBILITY
M. COUNTABLE RESOURCES
$
$
$
$
1.
Total Resources
2.
Maximum Resource Level
$
$
$
$
3.
Resource Eligible?
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
(Is M1 less than or equal to M2?)
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
N. RESOURCE OVERISSUANCE (
)
IF M3 IS NO
$
$
$
1.
Amount Previously Issued/Authorized
$
$
2.
Correct Benefit
$
$
$
$
$
$
3.
Total CalFresh Overissuance (N1-N2)
$
$
4.
Minus Lost Benefits Not Restored
$
$
$
5.
Minus Payment Received
$
$
$
$
6.
Amount of Overissuance to be Collected
(N3-N4-N5)
$
$
$
$
$
$
$
7.
Minus Workfare Offset
$
8.
Amount of Overissuance to be Collected (N6-N7)
$
$
$
$
PART 4 - NON-FINANCIAL ELIGIBILITY
O. HOUSEHOLD COMPOSITION
1.
Previous Household Size
2.
Correct Household Size
P.
NON-FINANCIAL OVERISSUANCE
$
1.
Amount Previously Issued/Authorized
$
$
$
2.
Correct Benefit
$
$
$
$
3.
Total CalFresh Overissuance (P1-P2)
$
$
$
$
4.
Minus Lost Benefits Not Restored
$
$
$
$
5.
Minus Payment Received
$
$
$
$
6.
Amount of Overissuance to be Collected
$
(P3-P4-P5)
$
$
$
7.
Minus Workfare Offset
$
$
$
$
8.
Amount of Overissuance to be Collected (P6-P7)
$
$
$
$
NA 1263 (8/11) CONTINUATION PAGE
Page _________ of ________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Na 532 - Notice Of Action (continuation Page) - 48-month Time Limit Discontinue - Includes Budget
Legal
Form Na 531 - Notice Of Action (continuation Page) - 48-month Time Limit - Adult Reached Calworks - Includes Budget
Legal
Form Na 1218 - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment
Legal
Related Categories
Parent category: Legal