Form Na 1214 - Notice Of Action - Change Under/overpayment
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1
2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION - CHANGE
Notice Date :
Case
UNDER/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.
INSTRUCTIONS:
Use to notify of an overpayment
and subsequent grant adjustment. Specify the amount
owed and the reason for the overpayment and the
appropriate reg cites.
Attach the appropriate Continuation Page (NA 274B, C,
D or E) to show the overpayment computation. Attach
the NA 275 to show the grant adjustment amount.
As of ____________, The County is changing your
Kin-GAP cash aid for
from $
to
$_______. You were overpaid a total of $ __________.
Here’s why:
You do not have to use any Social Security or SSI
benefits you get to repay this overpayment.
The next page(s) show how much Kin-GAP cash aid
you should have been paid for each month you were
overpaid, the total amount you owe, and how much will
be taken out of each month’s Kin-GAP cash aid
amount.
Your new Kin-GAP cash aid amount is figured on this
page.
WARNING: If you think this overpayment is wrong, this
is your last chance to ask for a hearing. The back of
this page tells how. If the child stays on aid, the County
can collect a Kin-GAP overpayment by lowering the
child’s monthly grant.
NA 1214 (2/00)
Page ____ of ____
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