Form Temp Na 820a - Notice Of Action
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2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF ACTION
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 you how.
For the period of _______________until _______________, the
public transportation
your car’s mileage
County has approved your transportation for participating in your
allowable Welfare to Work activity.
_____ rate
_____ rate
X
_____ per_____
x _____ per_____
The most we can pay is $ _______for a total of _____ miles
=$ _____
x _____ miles
per ________.
=$ _____
The County has approved $ __________ per ____________
based on public transportation rates.
parking
The County has approved bus passes or tickets for a total of
$ _______
month
school term
other
__________ per __________.
total back payments due/month from __________ through
The County will only pay for transportation while you were
__________
attending your allowable Welfare to Work activity:
0 /
$_____ month
$_____/_____
___________________________________________________ .
$_____/_____
$_____/_____
Your transportation payment limit is figured on this notice.
$_____/_____
$_____/_____
Mileage for driving can be paid only if there was no public
transportation available, or it cost the same or less than public
$_____/_____
$_____/_____
transportation. Public transportation was available when it took a
$_____/_____
$_____/_____
two hour or less round trip to get you from your home to your
activity on time. You cannot count time it took you to go to and
$_____/_____
$_____/_____
from your child’s school or child care. If you drove your car even
$_____/_____
$_____/_____
though public transportation was available, you will be paid at the
public transportation rate or the mileage rate, whichever is lower.
$_____/_____
$_____/_____
Your transportation payments will be
Advanced to you
$_____/_____
$_____/_____
Paid back to you
Paid to your transportation provider
$_____/_____
$_____/_____
Other:
$_____/_____
$_____/_____
You can call your Welfare to Work worker if you have questions.
$_____/_____
$_____/_____
total amount for all periods $____________
see attached page for calculation details
Rules: These rules apply. You may review them at your welfare
office: MPP 42-750.112
TEMP NA 820a (5/02) REQUIRED – NO SUBSTITUTE PERMITTED
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