Form Temp 2211 - Notice Of Action
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1
2STATE OF CALIFORNIA
COUNTY OF
NOTICE OF ACTION
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 you how.
SUPPORTIVE SERVICES
TRANSPORTATION CONTINUED:
ANCILLARY
CHILD CARE
The following items you asked for were not approved for
Your back child care costs from ______________________
payment:
through ____________________________ have been denied
Item
Amount
because:
_______________________________
$ _________________
Your child care costs were covered
_______________________________
$ _________________
Other:_________________________________________
_______________________________
$ _________________
_________________________________________________
Here’s why:
_________________________________________________
Payment for this item was not necessary because:
_________________________________________________
_________________________________________________
TRANSPORTATION
_________________________________________________
For the period from _____________________________ through
_________________________________________________
_____________________________________________ your
You did not need ___________________________________
welfare-to-work transportation payment you asked for is:
__________________________________________ for your
Denied
welfare-to-work activity because:
Less than you asked for (you will receive another notice to
You were not in an approved welfare-to-work activity
show you how the county figured this amount)
Other: ________________________________________
Here’s why:
_________________________________________________
You are already getting as much as the County can pay
_________________________________________________
because:
If you have any questions about this call your worker:__________
the maximum mileage rate is: $ ________ per ________.
___________________________ at (
) ________________.
Public transportation is available.
County-provided transportation is available.
You were not in an approved welfare-to-work activity.
You needed to travel less than one mile each way to get to you
approved welfare-to-work activity.
The transportation you asked for is not needed to attend your
Medi-Cal: This Notice of Action does NOT change or stop
approved welfare-to-work activity because:_______________
Medi-Cal benefits. Keep your plastic Benefits Identification
_________________________________________________
Card(s).
Other_____________________________________________
Rules: These rules apply. You may review them at your welfare
office: MPP 42-750.
_________________________________________________
TEMP 2211 (4/02) CalWORKs WELFARE-TO-WORK ACTIVITIES REVIEW FOR SUPPORTIVE SERVICES DENIAL FORM -REQUIRED – NO SUBSTITUTE PERMITTED
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