Form Na 1239 - Notice Of Action - Continuation Page - Quarterly 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
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
Questions? Ask your Worker.
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
Because your income changes, we have to average your income. To do
Section A. Countable Income, Month of ___________
that we add all of your reported income and divide by the number of
1.
Total Self-Employment Income . . . . . . . . . . . . . . . . . $ ___________
payments you reported. We then change that average to a monthly
2.
Self-Employment Expenses:
amount to figure your cash aid for the quarter. Here’s how:
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
OR
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
____________ Income Reported
$____________
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 . . . . = ___________
Total reported
____________
OR
# of payments reported
÷ ___________
7.
Unused DBI Disregard (up to $112) . . . . . . . . . . . . . . = ___________
8.
Net Earnings from Self-Employment (from above) . . + ___________
Average income =
$____________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
(apply multiplier)
x ___________
10. Unused Amount of $225 (from #7) or $112
(whichever is less) . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
Average monthly income =
$____________
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 . . . . . . . . . . . . . . . . . . . . - ___________
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 1 of ____
NA 1239 (9/11) CONTINUATION PAGE - QUARTERLY REPORTING BUDGET
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