Form Na 1209 - Notice Of Action - Change In The Amount Of Kin-Gap Payment
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2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION - CHANGE
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.
Your benefits may not be changed if you ask for a
hearing before this action takes place.
As of ____________, the County is changing your
Kin-GAP cash aid from $ ________ to $ _________
per month.
Here’s why:
The aid you got was for __________________.
There was a change in the amount of income
received.
The child’s age changed.
You will get an infant supplement on behalf of
__________________.
You
are
no
longer
eligible
to
receive
___________________.
Because you moved to_________________County.
Other ___________________________________.
Rules: These rules apply. You may review them at
your county welfare office: MPP Sections 90-110.1(g),
90-115.2, 11-301.2, .31 and .4.
NA 1209 (2/02) CHANGE IN THE AMOUNT OF KIN-GAP PAYMENT.
Page ____ of ____
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