Form Na 1231 - Cash Assistance Program For Immigrants - Notice Of Overpayment - Partial Waiver Approval

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Cash Assistance Program
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
for Immigrants
Notice Date :
Notice of Overpayment
Case
Name
:
- Partial Waiver Approval
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
(ADDRESSEE)
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.
Repaying the Overpayment
We previously notified you of your Cash Assistance Program for
Immigrants (CAPI) overpayment in the amount of $ ___________
for the period _________________ through _________________.
CHANGE IN BENEFITS
Your request for waiver of this overpayment is partially approved.
This means you will have to pay back $ ___________ of this
overpayment, but will NOT have to repay $ ___________ of this
Effective _________________, your CAPI payments are changed
overpayment.
from $ ___________ to $ ___________ because we will be
Recovery of an overpayment can be waived if BOTH of the
collecting $ ___________ per month to recover your CAPI
following are true:
overpayment.
•
You were not at fault in connection with causing or accepting
the overpayment.
If you prefer, you can repay the full amount. Contact your worker
AND
to find out how.
•
You could not pay your bills for food, clothing, housing,
medical care, or other necessary expenses if you had to pay
REPAYMENT REQUIRED BECAUSE YOU NO LONGER
us back.
RECEIVE CAPI BENEFITS
Your waiver request is being denied for part of this overpayment
because:
Repay the full amount or arrange to pay by installments. Contact
You made an incorrect statement or a statement you should
your worker to find out how.
have known was incorrect.
You failed to give us timely information that you knew or
should have known was important.
You accepted and cashed payments that you either knew or
should have known were incorrect.
You received and cashed duplicate payments for the same
period.
You have been overpaid in the past for similar reasons.
You can afford to pay your bills for food, clothing, housing,
medical care or other necessary expenses and still repay the
overpayment either in full or by installments.
Other (explain)
Medi-Cal: This notice does NOT change or stop Medi-Cal
benefits. If there is a change in your Medi-Cal benefits, you will
receive another notice. Keep your plastic Benefits
Identification Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP 49-001 through 49-070
NA 1231 (7/01)

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