Form Na 1217 - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Overpayment

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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 Overpayment
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 have paid you $ ________________ too much Cash Assistance Program for Immigrants (CAPI) benefits. The overpayment happened
from ______________________ through ______________________ . You were overpaid 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 to be repaid.
Amount Paid
Correct Amount
Month(s)/Year
Underpaid Amount
Overpaid Amount
Each Month
Each Month
Total amount of overpayment $ ________________
You must pay us back unless we decide that recovery of your overpayment can be waived. If you think you should not have to pay us back or
you disagree with the decision about the overpayment, you can ask for a waiver, a hearing, or both.
Repaying The Overpayment
There are two ways to repay the overpayment:
1.
You can refund the full amount. Contact your worker to find out how.
2.
If you are receiving CAPI now, or will receive CAPI in the future, we can withhold no more than 10 percent of your total income from your
monthly CAPI check.
If you are still receiving CAPI, and we do not hear from you in the next 30 days, we will withhold $ ________________ per month from your
check beginning ______________________ . If you ask for a waiver or appeal in the next 30 days, we won’t change your check until we
decide your case.
If You Think You Should Not Have To Repay The Overpayment
Sometimes recovery of an overpayment can be waived, which means that you will not have to pay us back. Recovery of an overpayment can
be waived if BOTH of the following are true:
You were not at fault in connection with causing or accepting the overpayment
AND
You could not pay your bills for food, clothing, housing, medical care, or other necessary expenses if you had to pay us back.
You can request a waiver by contacting your county worker who will send you the proper forms to fill out and return, or help you complete the forms.
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, Part6, Chapter
receive another notice. Keep your plastic Benefits
10.3, Sections 18937 through 18944; 20 CFR 416.558,
Identification Card(s).
20 CFR 416.537(a).
Page 1 of ____
NA 1217 (9/06)

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