Form Temp 2175 - Notice Of Action
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2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF ACTION
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
Questions? Ask your Worker.
(ADDRESSEE)
State Hearing: If you think this action is wrong,
you can ask for a hearing. The back of this page
tells how. Your benefits may not be changed if you
ask for a hearing before this action takes place.
Your welfare-to-work plan will be corrected to
You asked that the following problems(s) with your SIP be
fixed:
include____________________________.
______________________________________________
______________________________________________
Your back child care costs from ____________________
______________________________________________
through________________have been approved for a
total of $__________. See the attachment for how we
______________________________________________
computed your back child care costs. If you have any
______________________________________________
questions about this, call
________________________
Based on our review of your self-initiated-program request and
at____________________________________________
the information that you provided, the county has approved the
following action(s) to fix problems with your SIP.
Other ________________________________________
____________________________________________
Your current SIP or SIP extension has been approved
____________________________________________
for________ months beginning ______________________.
____________________________________________
You may start an approvable SIP. To be approved, you must
start school the next time you can enroll and no later than
the Spring 2000 school term. You may enroll later only if you
give the county a good reason why you could not start by
Spring 2000. You must continue to par ticipate in the
activities in your existing welfare-to-work plan until you
actually begin the activities in your corrected welfare-to-work
plan. The SIP will count as part of your welfare-to-work
activities for__________months.
Your hours for _______________________________will be
counted as part of your welfare-to-work activity.
Medi-Cal: This Notice of Action does NOT change or stop
Medi-Cal benefits. Keep your plastic Benefits Identification
Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP 42-711.54.
TEMP 2175 (7/99) SIP REVIEW REQUEST APPROVAL (REQUIRED FORM - NO SUBSTITUTES PERMITTED)
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