Form Na 991 - Notice Of Action - Refugee Cash Assistance (Rca)/entrant Cash Assistance (Eca) Mc-Decrease/expiration (Time-Expiration)
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice of Action
Refugee Cash Assistance (RCA)/Entrant Cash Assistance (ECA)
MC-Decrease/Expiration (Time-Expiration)
If you have questions or want more information about
this notice, please contact your worker.
Case Name:
Case Number:
Worker:
Phone:
Date:
•
•
•
•
Your monthly aid payment received under the Refugee Resettlement Program or Cuban/Haitian Entrant Program will be decreased from
$_____________ to $___________ on the effective date shown below. Your aid payment is based on the number of persons in your
household, and the following persons will be discontinued from cash aid and cash-based Medi-Cal effective_______________________
Persons:________________________________
________________________________
________________________________
Net Nonexempt Income Computation
Name
Name
Name
Total Earned Income
Disability Unearned Income
-
Computation Of Monthly Aid Payment
225+ 50% Disregard
-
Subtotal
=
Maximum Aid Payment for
Persons
Other Unearned Income
+
Special Needs (Specify)
+
+
+
+
Net Nonexempt Income
• Net Nonexempt Income
-
=
Total Grant
=
Overpayment Adjustment (see page
)
or
-
Monthly Aid Payment
• Net Nonexempt Income Total (columns 1 + 2 + 3) _____________________
=
_____________________
Your monthly aid payment and cash-based Medi-Cal received under the Refugee Resettlement Program or Cuban/Haitian Entrant
Program will be discontinued effective
.
You will receive a separate Notice of Medi-Cal-Only eligibility.
Other Medi-Cal Action:
Reason:
These changes are required by Federal regulations which limit refugee/entrant aid payments and cash-based Medi-Cal eligibility to 8 months
from the person's month and year of entry into the United States as a refugee, the date asylum was granted, or the date of certification as a
trafficking victim. It has been determined from a review of immigration documents that you or the persons named above will have exceeded
this period of eligibility on the effective date shown above.
Laws requiring this action:
Section 412 of the Refugee Act of 1980 (Public Law 96-212) or Section 501 of the Refugee Education Assistance Act of 1980 (Public Law
96-422), as implemented by 45 CFR parts 400 and 401; 45 CFR 205.10; California Code of Regulations, Title 22, Sections 50183(a)(3) and
50227.
Comments:
You or the persons discontinued may be eligible for further cash aid through other aid programs. Please contact your County Welfare
Department for more information. Refugees/Entrants receiving aid payments under the CalWORKs Program are not affected by this notice
or the 8-month eligibility time limit.
State welfare regulations are available for review at the local office of the County Welfare Department.
Information about family planning services is available from the County Welfare Department on request.
State Hearing. If you are dissatisfied with this action, your aid may continue unchanged if you ask for a State Hearing before the
effective date of the action. Read the back for important information about your right to appeal this action.
NA 991 (10/03) RCA/ECA, MC-Decrease/Expiration (time-expiration)
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