Form Na 834 - Notice Of Action - Child Care Denial
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHILD CARE DENIAL
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 find
out how to ask for a hearing.
Sanctioned Cases:
DATE
NAME OF CHILD
If you are being sanctioned and need child care for activities that
are not approved by the county, you may still be eligible for Stage
Two child care or another state or federally funded child care and
development program. If you are being sanctioned and engaged in
PROVIDER
activities that are not approved by the county, you may ask the
MONTH
county for help in transferring you to other child care for which you
may be eligible. You may also apply on your own to the Resource
and Referral agency listed below.
NAME OF CHILD
Notes
NAME OF CHILD
DATE
NAME
Rules: These rules apply. You may review them at your welfare
office: CalWORKs MPP Sections 42-713.2, 47-260, 47-430.2,
47-620.32; Education Code Sections 8350-8353, 8357.
Welfare
& Institutions Code Sections 11322.9, 11323.6, 11323.4 and
11323.8, or visit or
REASON
To see if you may qualify for other child care programs, you can contact
the local Child Care Resource and Referral agency listed below:
Name: _________________________ Telephone: ________________
Address: _____________________________________________
Page 1 of ____
NA 834 (8/15) REQUIRED FORM - SUBSTITUTES PERMITTED
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