Form Na 1239 Ar - Notice Of Action - Continuation Page - Annual Reporting Budget
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Continued
Notice Date:
Case Name:
Case Number:
Worker Name:
Worker Number:
Telephone:
Worker Hours:
24 Hour Information:
Address:
Questions? Ask your worker or call the number above.
State Hearing: If you think this action
is wrong, you can ask for a hearing.
The back of this page tells how. Your
benefits may not be changed if you ask
for a hearing before this action takes
place.
Monthly Cash Aid Amount
You reported income that you do not expect to
Section A. Countable Income, Month of ___________
change. When you get paid every week or every
1.
Total Self-Employment Income . . . . . . . . . . . . . . . . . $ ___________
2.
Self-Employment Expenses:
other week, here is how we figure your monthly
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
income:
OR
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = ___________
First, we add all the income you got in the month
4.
Total Disability-Based Unearned Income (DBI)
(Assistance Unit + Non-Assistance Unit Members) . $ ___________
and divide by the total number of payments you
5.
$225 DBI Disregard (if #4 is greater than $225) . . . . - ___________
got. Then, we multiply that amount by the
6.
Nonexempt Unearned Disability-Based Income . . . . = ___________
OR
average number of payments in a month.
7.
Unused DBI Disregard (up to $112) . . . . . . . . . . . . . . = ___________
8.
Net Earnings from Self-Employment (from above) . . + ___________
● If you get paid every week, you may get paid 4
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
10. Unused Amount of $225 (from #7) or $112
or 5 times in a month. 4.33 is the average
(whichever is less) . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
11. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
number of payments in a month.
12. Earned Income Disregard 50%. . . . . . . . . . . . . . . . . . - ___________
13. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
● If you get paid every other week, you may get
14. Nonexempt Unearned Disability-Based Income
(from #6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
paid 2 or 3 times in a month. 2.167 is the
15. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
16. Other Nonexempt Income (Assistance Unit + Non-
average number of payments in a month.
Assistance Unit Members) . . . . . . . . . . . . . . . . . . . . . + ___________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Here’s your information:
Section B. Your Cash Aid, Month of ____________
1.
Maximum Aid ______ Persons
__________ Income Reported
$_________
(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) . . . . . . . . . . $ ___________
+$_________
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + ___________
=$_________
Total Reported
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Full Month Aid Subtotal
÷_________
# of Payments Reported
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = ___________
=$_________
Weekly Amount
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = ___________
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - ___________
x_________
Multiplied by
Other Penalties . . . . . . . . . . . . . . . . . . - ___________
=$_________
Monthly Amount
Overpayment . . . . . . . . . . . . . . . . . . . . - ___________
School Bonus ($100 or $500) . . . . . . . + ___________
11. Monthly Cash Aid Amount
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
12. Current Cash Aid Amount (If This Amount is more
Than #11, Your Cash Aid Will Not Change) . . . . . . . . = ___________
Page ____ of ____
NA 1239 AR (10/12) CONTINUATION PAGE - ANNUAL REPORTING BUDGET - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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