Form Na 1213 - Notice Of Action - Discontinue Restricted Account
Download a blank fillable Form Na 1213 - Notice Of Action - Discontinue Restricted Account in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Na 1213 - Notice Of Action - Discontinue Restricted Account with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION -
Notice Date :
Case
DISCONTINUE RESTRICTED
Name
:
Number
:
ACCOUNT
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.
1. Restricted Account(s) Total.................. $ ___________
Kin-GAP
INSTRUCTIONS:
Use to discontinue
cash aid
2. Spending Allowed ................................ - ___________
and apply penalty period when there has been misuse of a
restricted account. Fill in the effective date of the
3. Subtotal ............................................... = ___________
discontinuance. Fill in the Kin-GAP child’s name. Fill in the
4. Basic Need, ____ Persons .................. $ ___________
date of the end of the period of ineligibility. Check the
5. Special Needs .................................... + ___________
applicable box(es). Print the computation on the right hand
6. Basic Need Subtotal ............................ = ___________
side of the NA 290 and fill in the computation section.
7. Period of Months.................................. = ___________
As of ____________, the County is stopping your
The child may still continue to get Medi-Cal if the child’s Kin-
Kin-GAP aid for ____________ until ____________.
GAP aid stops.
Here’s why:
Please complete and send in the enclosed Transitional
Medi-Cal (TMC) form.
The child got money from the child’s restricted account.
Then, within 30 days of the time the child got the money,
the child didn’t:
Spend the money on an allowable expense.
Put back into the account the part of the money that
.
wasn’t needed for the child’s allowable expense
Give the County proof of the amount the child took
out of the account.
Give the County proof of the balance in the account
before the child took out the money.
Give the County proof of what the child did with the
money.
If any boxes above are checked, it is because you were late
and missed a deadline. To stop this county action (and
Kin-GAP
restart the child’s
cash aid before the end of the
time period), you must prove to the County that you had a
good reason for being late. Let your worker know right away.
The child got money from his/her restricted account and
spent some or all of it on expenses that are not allowed.
Interest was paid out on the child’s restricted account.
NA 1213 (2/00)
Page ____ of ____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Na 532 - Notice Of Action (continuation Page) - 48-month Time Limit Discontinue - Includes Budget
Legal
Form Na 403a - Notice Of Action - Approval, Change Or Discontinued For Kinship - Guardians Only
Legal
Form Na 1218 - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment
Legal
Related Categories
Parent category: Legal