Form Na 1261a - Notice Of Action - Form And Instructions- For Approved Relatives, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians Or Non-Minor Dependents Residing In A Supervised Independent Living Setting
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FORM AND INSTRUCTIONS -
(4) Notice Date:
For Approved Relatives, Non-Relative Extended
(5) Case Name:
Family Members, Foster Family Homes, Non-
(6) Case WorkerNumber:
Related Legal Guardians or Non-Minor
Dependents Residing In A Supervised
(7) Case Worker Name:
Independent Living Setting:
(8) Case Number:
(9) Telephone:
(10) Address:
(1) Name:
(2) Address:
(3) City, State Zip:
(19) Insert overpayment calculations and substantiation of time
periods by month as required in regulation. See MPP Section 45-
This is to inform you that you were overpaid AFDC-Foster Care benefits
305. Attach a page if additional space is needed.
(11) for
for
(NAME OF CHILD)
(12) the period of __________________ to __________________
(MM/DD/YYYY)
(MM/DD/YYYY)
(13) Total amount you received: $ __________________________
(14) Total amount you should have received:$ _________________
(15) Total amount of Overpayment: $ ________________________
(16) Date of Discovery: ______________ Collection is permitted if
demand within one year of discovery.
(17) You are required to repay the overpayment amount of
$__________________.
(18) Reason for the overpayment:
I
(A) From ______________________ (date) the child/youth was
not residing in your home and you failed to report that 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 foster care overpayments if the adult caretaker
caused the overpayment. We cannot require you to repay the
overpayment if you meet an exception. Exceptions to repayment
are:
The overpayment was exclusively caused by county
G
administrative error, 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 used
G
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, you may request a hearing. Please see
following pages for hearing instructions.
If you agree with the reason for overpayment 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 payment agreement. You must contact the
worker at the top of this page to discuss the terms of a written
payment agreement.
Relevant Law: Welfare and Institutions Code section 11466.24,
If you have any questions regarding the overpayment computation or
Manual of Policies and Procedures (MPP) sections 22-009, 45-
repayment arrangements, please contact the worker at the top of this
304, 45-305, and 45-306.
form.
NA 1261A (1/16) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE___ OF ___
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