Form Temp 2172 - Notice Of Action

Download a blank fillable Form Temp 2172 - Notice Of Action in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Temp 2172 - Notice Of Action with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE 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 school says that you did not make satisfactory
You asked that the following problems(s) with your SIP be
progress.
fixed:
The program is not on the county’s list of programs
leading to a job and you did not show that your school
______________________________________________
program would lead to a job that would take you off cash
______________________________________________
aid.
______________________________________________
You were in a private, post-secondary school that was
______________________________________________
not approved by the appropriate State regulatory agency.
______________________________________________
You were enrolled in an educational program that did not
meet SIP approval rules. You were approved to continue
Based on our review of your self-initiated-program request and
until the beginning of the next semester or quarter. At
the information that you provided, your request has been
that time, you did not move to a program that met SIP
denied. Here’s why:
approval rules and that was approved by the county.
Your SIP Review Request Form was received after
Your request for back child care costs from __________
October 29, 1999.
through_________________has been denied because
You did not give us the additional information/documentation
____________________________________________
we asked for on __________________________.
____________________________________________
You applied to the wrong county. You must apply to
If you have any questions about this, call ____________
________________________________ County.
_____________________at______________________.
You were not sanctioned because of your SIP.
You were not enrolled in your SIP on the date of your
Other ________________________________________
appraisal on __________________________.
____________________________________________
You were not enrolled in your SIP on the date you were
scheduled for appraisal and you failed to go to your appraisal
appointment and you did not have a good reason.
You already have a bachelor’s degree and your program is
not a teaching credential program.
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 2172 (9/99) SIP REVIEW REQUEST DENIAL (REQUIRED FORM - NO SUBSTITUTES PERMITTED)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2