Form Na 1242 - Notice Of Action - Sanctions Budget
Download a blank fillable Form Na 1242 - Notice Of Action - Sanctions Budget 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 1242 - Notice Of Action - Sanctions Budget 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
1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date :
__________________________________________________________________________
Case
Name
:
__________________________________________________________________________
Number
:
__________________________________________________________________________
You reported the following income for the quarter.
Monthly Cash Aid Amount
Section A. Countable Income, Month of ___________
Month ________________
1.
Total Business Income . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
2.
Business Expenses:
Month ________________
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
OR
Month ________________
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = ___________
4.
Total Disability-Based Unearned Income (DBI)
(Assistance Unit + Non-Assistance Unit Members) . $ ___________
5.
$225 DBI Disregard (if #4 is greater than $225) . . . . - ___________
6.
Nonexempt Unearned Disability-Based Income . . . . = ___________
OR
7.
Unused DBI Disregard (up to $112) . . . . . . . . . . . . . . = ___________
8.
Net Earnings from Self-Employment (from above) . . + ___________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
10. Unused Amount of $225 (from #7) or $112
(whichever is less) . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
11. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
12. Earned Income Disregard 50%. . . . . . . . . . . . . . . . . . - ___________
13. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
14. Nonexempt Unearned Disability-Based Income
(from #6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
15. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
16. Other Nonexempt Income (Assistance Unit + Non-
Assistance Unit Members) . . . . . . . . . . . . . . . . . . . . . + ___________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Section B. Your Cash Aid, Month of ____________
1.
Maximum Aid ______ Persons
(Assistance Unit + Non-Assistance Unit Members) . . $ ___________
2.
Special Needs (Assistance Unit + Non-Assistance
Unit Members) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
3.
Net Countable Income from Section A (above) . . . . . - ___________
4.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
5.
Maximum Aid ______ Persons (Assistance Unit only)
(Excluding MFG, or Penalized Persons) . . . . . . . . . . $ ___________
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + ___________
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Full Month Aid Subtotal
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = ___________
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = ___________
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - ___________
Other Penalties . . . . . . . . . . . . . . . . . . - ___________
Overpayment . . . . . . . . . . . . . . . . . . . . - ___________
Child-Only Grant Cut (5%, 10%, 15%) . - ___________
School Bonus ($100 or $500) . . . . . . . + ___________
11. Monthly Cash Aid Amount
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
NA 1242 (4/11) CONTINUATION PAGE - SANCTIONS BUDGET - REQUIRED - SUBSTITUTES PERMITTED
Page 2 of ___
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal