Form Wtw 11 - Welfare To Work/cal-Learn Supportive Services Overpayment/underpayment Notice

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
WELFARE TO WORK/CAL-LEARN SUPPORTIVE SERVICES OVERPAYMENT/UNDERPAYMENT NOTICE
COUNTY OF:_______________________________________________
NOTICE DATE:
CASE NAME:
ADDRESSEE:
CASE NUMBER:
WORKER'S NAME:
You were overpaid for the following Supportive Services(s) for the month(s) of_____________________________________________ :
Transportation expenses
Work/training related expenses
Education related expenses
HERE'S WHY:
You did not have good reason for not participating in the following assigned activity __________________________________________
and were not eligible for supportive services.
You were paid an advance payment for ____________________________________ that you did not use to pay for Welfare to
Work/Cal-Learn expenses.
Other:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
You have an underpayment in
Transportation expenses
Education related expenses
Work/training related expenses; of $____________ because of ____________________.
The following shows how much you were paid or what the County paid for you, the amount that should have been paid and the total amount
you owe.
AMOUNT PAID......................................................
$
$
$
$
LESS AMOUNT YOU SHOULD
- $
- $
- $
- $
HAVE BEEN PAID.................................................
=$
=$
=$
=$
OVERPAYMENT AMOUNT...................................
TOTAL OVERPAYMENT (YOU OWE) FROM THIS NOTICE .............................................................................................
=$
PLUS TOTAL PREVIOUS UNCOLLECTED OVERPAYMENT...........................................................................................
+$
LESS UNDERPAYMENT .....................................................................................................................................................
- $
NEW TOTAL AMOUNT YOU OWE.....................................................................................................................................
=$
=$
TOTAL AMOUNT WE OWE YOU .......................................................................................................................................
ONLY THE BOXES THAT ARE CHECKED BELOW APPLY TO YOU:
You must pay back what you owe. You have 10 days from the date this notice was mailed to you to:
pay in full what you owe,
complete and return the enclosed repayment agreement or,
call your county at ___________________________________________________to discuss a repayment agreement with the County.
If you don't pay what you owe or contact your County within 10 days after the date this notice was mailed to you, the County will collect the
overpayment by lowering your supportive services payment.
The amount collected will be 5% of your supportive services payment if the overpayment was caused by the County or 10% of your
supportive services payment if the overpayment was caused by you.
The overpayment collection will continue for each month you request a payment until the amount you owe is paid back. This means that
your next supportive services payment of up to $______________ will be lowered by no more than $ _____________ .
You may not have to repay in any month while you are in Welfare to Work/Cal-Learn if you would:
not have enough money to pay for child care, transportation and or work/training related expenses and/or education related
expenses to be in Welfare to Work/Cal-Learn and/or
have to change the child care arrangements you have now.
Call your worker/Case Manager to have your repayment delayed, if either of the reasons above apply to you.
You have told the County before that you cannot begin to repay the overpayment while you are in Welfare to Work/Cal-Learn. The
County will delay this repayment.
CONTACT YOUR WORKER/CASE MANAGER IF YOU THINK THIS NOTICE IS WRONG. YOU MAY ALSO ASK FOR A STATE
HEARING. "YOUR HEARING RIGHTS" FORM TELLS YOU HOW TO ASK FOR A STATE HEARING.
If you go off aid before the overpayment is paid back and you do not continue to repay, the County may take what you owe out of your state
income tax refund or take other action to collect.
You do not have to use any Social Security or SSI benefits you get to repay this overpayment.
If you pay by check or money order send or bring it to:
Address:
If you pay by cash, pay in person. DO NOT MAIL CASH. Be sure to ask for a numbered receipt with the County's name on it.
RULES: These rules apply: CALWORKS Implementation Guidelines Section VII, Welf. & Inst. Code 11004, 11323.4
WTW 11 (7/99) REQUIRED/SUBSTITUTE PERMITTED

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