Form Temp Na 1237 - Notice Of Action
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1
2
3NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
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.
The county owes you back cash aid of $ ___________________ .
Here’s why:
You were denied cash aid because you had too much income. State
law has changed and you are now eligible for back cash aid for a
month(s) between October 2002 and July 2003. The amount is figured
on the next page.
Medi-Cal: This notice DOES NOT change or stop Medi-Cal
Benefits. Keep using your plastic Benefits Identification
Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP 44-207.1.
TEMP NA 1237 (8/03) RETROACTIVE ELIGIBILITY (MBSAC)
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