Form Na 841 - Notice Of Action - Welfare-To-Work Plan
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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
number of days. See the back of this
notice for more information and to
_________________________ , our records show that you did not:
find out how to ask for a hearing.
■
Sign the Welfare-to-Work plan on ________________________ .
■
HOW TO STAY IN WELFARE-TO-WORK
Participate in ___________________ on ___________________.
■
As of ________________________ , you will be taken out of
Make good progress in your_________________ activity because
Welfare-to-Work unless you show us you had a good reason for
____________________________________________________.
not doing what we asked you to do. If you do not have a good
■
reason, you can agree to a compliance plan to stay in
Accept a job at ________________________________________.
Welfare-to-Work. If you do not agree to a compliance plan, you
■
Keep your job at ______________________________________.
will not get another notice before you are taken out of
Welfare-to-Work.
■
Keep the same amount of earnings.
We will not pay for transportation, or work- or training-related expenses
We will not change your cash aid grant amount.
if you are not in Welfare-to-Work. We may pay for child care, if you
work or attend school.
WE NEED TO TALK TO YOU
HOW TO GET BACK IN TO WELFARE-TO-WORK
To stay in Welfare-to-Work, we must talk with you about this problem.
An appointment has been made for you on _____________________ ,
If you are taken out of Welfare-to-Work, you may be able to get in again
at ______ o’clock, at ______________________ . If you need
at a later date. To find out when you may be able to participate again
transpor tation or child care to go to this meeting, call your
and what you must do, call the county at ____________________ .
Welfare-to-Work worker at the telephone number listed below.
DO YOU NEED FREE LEGAL HELP? You can get free help with this
Welfare-to-Work Worker’s Name: ______________________________
problem from:
Local Legal Aid Office: (
)
Telephone Number: ________________________________________
If you cannot go to this meeting, you must call your worker to set a new
________________________________________________________
time. Unless you have a good reason, you can change this meeting
State Welfare Rights Organization: (
)
only once. You can also call your worker to talk about the problem
instead of going to the meeting. You must call your worker to set a new
________________________________________________________
time to meet, or to talk about your problem on the telephone, by
______________________________ .
CalFresh: If the failure to meet Welfare-to-Work requirements also causes a
When you talk to your worker, you will be asked if you had a good
CalFresh penalty, you may not be able to get CalFresh benefits. If there is a
CalFresh penalty, you will get another notice telling you how long your
reason (“good cause”) for not doing what we asked you to do. If we
CalFesh benefits will be stopped.
verify that you had a good reason, we will not take you out of
Welfare-to-Work because of this problem. Some examples of good
reasons are not having child care or not having transportation. For
Medi-Cal: This Notice of Action does NOT change or stop Medi-Cal benefits.
other good reasons, see the “Request For Good Cause Determination”
Keep your plastic Benefits Identification Card(s).
form sent with this notice.
Rules: These rules apply: CalWORKs MPP § 42-712 (exemptions); 42-713
If you do not have a good reason for not doing what we asked you to
(good cause); 42-721 (noncompliance and good cause). CalFresh
do, you can agree to a compliance plan to meet Welfare-to-Work rules.
MPP § 63-407.521. You may review these rules at your welfare office.
We will not take you out of Welfare-to-Work if you agree to a
compliance plan and then do what it says. If you agree to a
compliance plan and then later do not do what it says, we will take you
out of Welfare-to-Work. If this happens, you will get a separate notice.
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NA 841 (3/14) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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