Form Temp Na 1228 - Notice Of Action
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1
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3NOTICE OF ACTION
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
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 how. Your benefits may not be changed if you
ask for a hearing before this action takes place.
PAYMENT CALCULATION
For the period ______________________ until _________________,
your Retroactive Welfare To Work transportation payment you asked for
is approved.
Month _________________ Year __________
The amount the County owes you is ___________________.
Public transportation
_______ rate
The County figured your payment as shown on the right hand side of
_______ per _________
=$ ______
this notice (and page 2, if needed) and a check
Your car’s mileage
is enclosed
will be sent soon
Your transportation payment limit is figured on this notice. Mileage can
_______ rate
______ per __________
be paid only if there is no public transportation available, or if it costs
=$ ______
the same or less than public transportation. Public transportation is
available when it takes two hours or less round trip to get you from your
Parking
home to your activity on time. You cannot count time to go to and from
your child’s school or child care. If you drive your car even though
public transportation is available, you will be paid at the public
=$ ______ month
school term
transportation rate or the mileage rate, whichever is lower.
other
Other: ______________ -
_______ rate
x ______ per ________
=$ _______
Rules: These rules apply. You may review them at your welfare
office: MPP sections 42-750.11 and 42-711.552.
Page 1 of ____
TEMP NA 1228 (6/01) RECOMMENDED FORM
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