Form Na 845 - Notice Of Action - Sanction And Removal Of The Other Parent'S Needs
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1
2NOTICE 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.
Your benefits may not be changed if
you ask for a hearing before this
action takes place. If you and the
county disagree or if you have not
heard back from your worker, do not
wait to ask for a hearing. You must
ask for the hearing before a certain
___________________________, our records show that you did not:
number of days. See the back of this
notice for more information and to find
Sign the Welfare-to-Work plan on _________________________.
out how to ask for a hearing.
Participate in ___________________ on ___________________.
Make good progress in your_________________ activity because
HOW TO STOP YOUR FAMILY’S CASH AID FROM BEING LOWERED
____________________________________________________.
Accept a job at ________________________________________.
As of ____________________, your family’s cash aid will be lowered
from $ ________ to $ _________ as shown on the following page,
Keep your job at ______________________________________.
unless you show us you had a good reason for not doing what we
Keep the same amount of earnings.
asked you to do. If you do not have a good reason, you can agree to a
compliance plan to keep your family’s cash aid from being lowered. If
WE NEED TO TALK TO YOU
you do not agree to a compliance plan, you will not get another notice
before your family’s cash aid is lowered.
To keep your family’s cash aid from being lowered, we must talk
with you about this problem. An appointment has been made for you
See the next page for more information about how we figured how much
on ________________________, at ____________ o’clock, at
your family will get if your family’s cash aid is lowered.
________________________.
If you need transportation or child care to go to this meeting, call your
We will not pay for transportation, or work- or training-related expenses if
Welfare-to-Work worker at the telephone number listed below.
you are off cash aid. We may pay for child care, if you work or attend
school.
Welfare-to-Work Worker’s Name: ____________________________
HOW TO GET YOURSELF BACK ON CASH AID
Telephone Number: _______________________________________
Your family’s cash aid is being lowered because you did not do what we
If you cannot go to this meeting, you must call your worker to set a new
asked you to do and you are being removed from the Assistance Unit. If
time. Unless you have a good reason, you can change this meeting
your family’s cash aid is lowered, you can get your portion of the cash aid
only once. You can also call your worker to talk about the problem
back if you are eligible for it by contacting the county and telling them you
instead of going to the meeting. You must call your worker to set a new
want your cash aid back; then doing what the county asks.
time to meet, or to talk about your problem on the telephone, by
TO CONTACT THE COUNTY ABOUT GETTING BACK ON CASH AID,
________________________.
CALL ______________________________________________________ .
When you talk to your worker, you will be asked if you had a good
reason (“good cause”) for not doing what we asked you to do. If we
The family’s other parent, ______________________, may also get cash
verify that you had a good reason, your family’s cash aid will not be
aid again if he/she is eligible for it by contacting the county and telling them
lowered because of this problem. Some examples of good reasons are
he/she wants cash aid back; then doing what the county asks.
not having child care or not having transportation. For other good
DO YOU NEED FREE LEGAL HELP? You can get free help with this
reasons, see the “Request For Good Cause Determination” form sent
problem from:
with this notice.
Local Legal Aid Office: (
)
Your family’s cash aid will also not be lowered if you can show us that
____________________________________________________________
you should have been exempt at the time you did not do your
Welfare-to-Work activity.
State Welfare Rights Organization: (
)
If you do not have a good reason for not doing what we asked you to
____________________________________________________________
do, you can agree to a compliance plan to meet Welfare-to-Work rules.
Your family’s cash aid will not be lowered if you agree to a compliance
If the failure to meet Welfare-to-Work requirements also
CalFresh:
plan and then do what it says. If you agree to a compliance plan and
causes a CalFresh penalty, you may not be able to get CalFresh
then later do not do what it says, your family’s cash aid will be lowered.
benefits. If there is a CalFresh penalty, you will get another notice
If this happens, you will get a separate notice.
telling you how long your CalFresh benefits will be stopped.
Rules: These rules apply: CalWORKs MPP § 42-712 (exemptions);
Medi-Cal: This Notice of Action does NOT change or stop Medi-Cal
42-713 (good cause); 42-721 (noncompliance and good cause).
benefits. Keep your plastic Benefits Identification Card(s).
CalFresh MPP § 63-407.521. You may review these rules at your
welfare office.
Page 1 of ___
NA 845 (3/14) REQUIRED FORM - SUBSTITUTES PERMITTED
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