Form Temp Na 1229 - Notice Of Action

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NOTICE 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.
For the period ______________________ until _________________,
your Retroactive Welfare To Work transportation payment you asked for
is Denied. Here’s why:
You were not in an approved Welfare to Work activity.
The transportation you asked for was not needed to attend your
approved Welfare To Work activity.
You did not complete and give the County the forms you were
asked to give them in order to get your transportation costs paid.
You have already been paid as much as the county can pay.
You did not file the Review Request Form by November 30, 2001.
Other:
Rules: These rules apply. You may review them at your welfare
office: MPP sections 42-750.11 and 42-711.552.
Page 1 of ____
TEMP NA 1229 (6/01) RECOMMENDED FORM

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