Form Na 840 - 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
__________________________ _____, our records show that you did not:
notice for more information and to
Sign the Welfare-to-Work plan on ____________________________.
find 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
Keep your job at __________________________________________.
$ __________ to $ __________ as shown on the following page, unless
Keep the same amount of earnings.
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
WE NEED TO TALK TO YOU
compliance plan to keep your family’s cash aid from being lowered. If
To keep your family’s cash aid from being lowered, we must talk with
you do not agree to a compliance plan, you will not get another notice
you about this problem. An appointment has been made for you on
before your family’s cash aid is lowered.
________________, at _____ o’clock, at _________________________.
If you need transportation or child care to go to this meeting, call your
See the next page for more information about how we figured how much
Welfare-to-Work worker at the telephone number listed below.
your family will get if your family’s cash aid is lowered.
We will not pay for transportation, or work- or training-related expenses if
Welfare-to-Work Worker’s Name: _______________________________
you are off cash aid. We may pay for child care, if you work or attend
Telephone Number: __________________________________________
school.
If you cannot go to this meeting, you must call your worker to set a new
HOW TO GET YOURSELF BACK ON CASH AID
time. Unless you have a good reason, you can change this meeting only
Your family’s cash aid is being lowered because you did not do what we
once. You can also call your worker to talk about the problem instead of
asked you to do and you are being removed from the Assistance Unit. If
going to the meeting. You must call your worker to set a new time to meet,
your family’s cash aid is lowered, you can get your portion of the cash aid
or to talk about your problem on the telephone, by ___________________ .
back if you are eligible for it by contacting the county and telling them you
want your cash aid back; then doing what the county asks.
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 verify that you
TO CONTACT THE COUNTY ABOUT GETTING BACK ON CASH AID,
had a good reason, your family’s cash aid will not be lowered because of
CALL ______________________________ .
this problem. Some examples of good reasons are not having child care or
not having transportation. For other good reasons, see the “Request For
DO YOU NEED FREE LEGAL HELP? You can get free help with this
Good Cause Determination” form sent with this notice.
problem from:
Your family’s cash aid will also not be lowered if you can show us that you
Local Legal Aid Office: (
)
should have been exempt at the time you did not do your Welfare-to-Work
activity.
____________________________________________________________
If you do not have a good reason for not doing what we asked you to do,
State Welfare Rights Organization: (
)
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 plan and
____________________________________________________________
then do what it says. If you agree to a compliance plan and then later do
not do what it says, your family’s cash aid will be lowered. If this happens,
you will get a separate notice.
CalFresh: If the failure to meet Welfare-to-Work requirements also causes
a 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
Rules: These rules apply: CalWORKs MPP § 42-712 (exemptions);
CalFresh benefits will be stopped.
42-713 (good cause); 42-721 (noncompliance and good cause).
CalFresh MPP § 63.407.521. You may review these rules at your welfare
Medi-Cal: This Notice of Action does NOT change or stop Medi-Cal benefits.
office.
Keep your plastic Benefits Identification Card(s).
Page 1 of ____
NA 840 (3/14) REQUIRED FORM - SUBSTITUTES PERMITTED
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