Form Na 1230 - Cash Assistance Program For Immigrants - Notice Of Overpayment - 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
:
- 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.
We previously notified you of your Cash Assistance Program for
Immigrants (CAPI) overpayment in the amount of $ ___________
for the period _________________ through _________________.
Your request for waiver of this overpayment is approved. This
means you will NOT have to pay the money back.
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 1230 (7/01)

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