Form Temp Na 1221 - Notice Of Action
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1
2NOTICE 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.
As of __________________, the county has approved your back cash
aid of $_________________.
HERE'S WHY:
A court has told us to count child support in a new way. Child support
payments made for a minor parent can no longer be counted in
determining cash aid for the minor parent’s child.
Your back cash aid is figured on the next page.
A check will be sent soon.
A check is enclosed.
You have an existing overpayment balance. Some or all of your
back cash aid was used to lower the overpayment amount.
If you get Food Stamps, we will count your back cash aid as a
resource.
You may get another notice from Food Stamps.
Rules: These rules apply. You may review them at your welfare
office: Dominika v. Saenz
Page 1 of ____
TEMP NA 1221 (2/01) RETROACTIVE APPROVAL DOMINIKA V. SAENZ
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