Form Temp Na 1236 - Notice Of Action

Download a blank fillable Form Temp Na 1236 - Notice Of Action in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Temp Na 1236 - Notice Of Action with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
DENY - FINANCIAL ELIGIBILITY
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.
Family’s Total Earned Income
As of ____________________ , the county has denied your request for
back cash aid.
(Assistance Unit + Non-Assistance Unit Members) . $
$90 Disregard for each employed person . . . . . . . . . -
Here’s Why:
Other Nonexempt Income (Assistance Unit + Non-
Between October 2002 and July 2003, you were denied cash aid
Assistance Unit Members) . . . . . . . . . . . . . . . . . +
because you had too much income. State law changed raising the
(A) Net Countable Income . . . . . . . . . . . . . . . . . . . =
amount of income applicants can make and be eligible for cash
aid. After reviewing your application using the higher amounts
allowed, your income is still more than the need standard set by
Family Needs
the State for a family of your size.
Basic Need for ______Persons
You did not apply for cash aid between October 2002 and July
(Assistance Unit + Non-Assistance Unit Members) . $
2003.
Special Needs (Assistance Unit + Non-Assistance
You were denied because you had property that was worth more
Unit Members ) . . . . . . . . . . . . . . . . . . . . . . . . . +
than the allowed limits.
(B) Family Needs . . . . . . . . . . . . . . . . . . . . . . . . . . =
You were denied because you failed to provide information or proof
needed to determine your eligibility.
You were denied because there was no eligible child(ren) living in
the home.
Other:
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 1236 (8/03) RETROACTIVE ELIGIBILITY - DENY (MBSAC)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2