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)