Form Na 1218 - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment

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NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Cash Assistance Program For Immigrants
Notice Date :
Case
Notice of Underpayment
Name
:
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 you how.
Your benefits may not be changed if you ask for a
hearing before this action takes place.
We underpaid you $ ________________ in Cash Assistance Program for Immigrants (CAPI) benefits. The underpayment happened from
______________________ through ______________________ . You were underpaid because:
(MONTH/YEAR)
(MONTH/YEAR)
The following table shows the incorrect amount you received, the correct amount you should have received for each month, and the total amount
owed to you.
Amount Paid
Correct Amount
Underpaid Amount
Overpaid Amount
Month(s)/Year
Each Month
Each Month
Total amount of underpayment: $ _____________________
We will send you a check to repay you the CAPI benefits we owe you for the amount and the period shown above. Contact your worker if you
do not receive the check within two weeks.
Medi-Cal: This notice does NOT change or stop Medi-Cal
Rules: These rules apply; you may review them at your welfare
benefits. If there is a change in your Medi-Cal benefits, you will
office: Welfare and Institutions Code Division 9, Part 6, Chapter
receive another notice. Keep your plastic Benefits
10.3, Sections 18937 through 18944; 20 CFR 416.558 and
Identification Card(s).
20 CFR 416.536
Page 1 of ____
NA 1218 (9/06)

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