Form Temp 2174 - Notice Of Action
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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. The back of this page tells how. Your
benefits may not be changed if you ask for a hearing
before this action takes place.
The county incorrectly applied the Self-Initiated Program (SIP)
rules. To correct the problem we have removed your sanction for
the period of _________________ through _________________ .
You chose not to receive back cash aid for these months. For
that reason, the months will not count against your 60-month
time limit.
You chose to receive back cash aid for the months you were
sanctioned. Because you chose to get cash aid payments,
these months will count against your 60-month time limit.
Your back cash aid is figured on the next page.
A check will be sent soon.
A check is enclosed.
If you get Food Stamps we will count your back cash aid as a
resource.
You may get another notice from Food Stamps.
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 42-700
Page 1 of ____
TEMP 2174 (6/99) SIP REVIEW REQUEST CASH AID APPROVAL
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