Form Temp 2174a - Notice Of Action
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1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date : ____________________________________________________________________________
Case
Name
: ____________________________________________________________________________
Underpayment Amount Owed
Number
: ____________________________________________________________________________
(For Underpayments Occurring on or after 1-1-98)
Worker
Name
: ____________________________________________________________________________
Number
: ____________________________________________________________________________
Underpayment Month and Year:
______________
______________
______________
______________
______________
A Net Countable Income
Total Business Income
$
______________
______________
______________
______________
______________
Business Expenses
A. 40% Standard OR
–
______________
______________
______________
______________
______________
B. Actual
–
______________
______________
______________
______________
______________
Net Earnings from Self Employment
=
______________
______________
______________
______________
______________
Total Disability-Based Unearned Income
(Assistance Unit (AU) + Non Assistance
Unit (Non-AU) Members)
$
______________
______________
______________
______________
______________
$225 Disregard
–
______________
______________
______________
______________
______________
Nonexempt Unearned Disability-Based
Income OR
=
______________
______________
______________
______________
______________
Unused Amount of $225 Disregard
=
______________
______________
______________
______________
______________
Total Earned Income
$
______________
______________
______________
______________
______________
Net Earnings from Self-Employment
+
______________
______________
______________
______________
______________
(from above)
Subtotal
=
______________
______________
______________
______________
______________
Unused Amount of $225 Disregard
–
______________
______________
______________
______________
______________
Earned Income Disregard 50%
–
______________
______________
______________
______________
______________
Nonexempt Unearned Disability-Based
Income (from above)
+
______________
______________
______________
______________
______________
Other Nonexempt Income (AU + Non-AU
Members)
+
______________
______________
______________
______________
______________
Net Countable Income
=
______________
______________
______________
______________
______________
B Correct Cash Aid Payment
Maximum Aid Payment (# persons) $ Amount
(
)
(
)
(
)
(
)
(
)
______________
______________
______________
______________
_____________
(AU + Non-AU Members)
Special Needs (AU + Non-AU Members)
+
______________
______________
______________
______________
_____________
Net Countable Income
–
______________
______________
______________
______________
______________
Subtotal A
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Maximum Aid Payment (MAP)
(AU Only)
$
______________
______________
______________
______________
______________
Special Needs (AU only)
+
______________
______________
______________
______________
______________
Subtotal B
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Correct Cash Aid Amount
(Lesser of Subtotal A or B)
$
______________
______________
______________
______________
______________
C
Child Support Penalty Adjustment
25% Child Support Penalty
–
______________
______________
______________
______________
______________
Subtotal C
=
______________
______________
______________
______________
______________
D
Adjustments
a. Additional 25% Child Support Penalty
–
______________
______________
______________
______________
______________
b. Overpayment
–
______________
______________
______________
______________
______________
c. Cal-Learn Penalty
–
______________
______________
______________
______________
______________
d. Cal-Learn Bonus
+
______________
______________
______________
______________
______________
Adjusted Cash Aid:
Subtotal D
=
______________
______________
______________
______________
______________
E Underpayment
Correct Cash Aid Amount
$
______________
______________
______________
______________
______________
Cash Aid Paid To You
–
______________
______________
______________
______________
______________
Subtotal E
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Amount of Underpayment for Each Month
=
______________
______________
______________
______________
______________
TOTAL UNDERPAYMENT (All Months)
$ ______________
Rules: These rules apply; you may review them at your Welfare Office: MPP 44-340.
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of Page 1 tells how.
Page____ of ____
TEMP 2174A (6/99) CONTINUATION PAGE - SIP REVIEW (UNDERPAYMENT COMPUTATIONS FOR 1-1-98 AND AFTER)
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