Form Na 822 - Notice Of Action - Transportation Change
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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 :
(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
you how. Your benefits may not be
changed if you ask for a hearing
before this action takes place.
Your transportation payment calculation is shown on this notice.
I
I
Welfare to Work
Cal-Learn
As of _____________________ until ___________________
Mileage can be paid only if there is no public transportation available,
I
The County has changed your mileage transportation payment
or if driving your car costs the same or less than public transportation.
from $____________ to $_____________ for a total of
Public transportation is available when it takes two hours or less
___________ miles per ____________.
round trip to get you from your home to your activity on time. Time
going to and from your child's school or child care is not counted in
I
The County has changed your public transportation payment from
how long it takes you to get to your activity. If you drive your car even
$________ to $ _______ per ______________.
though public transportation is available, you will be paid at the public
I
The County has changed your bus ticket payment from_________
transportation rate or the mileage rate, whichever is lower.
to _________ per_____________.
Unless it is an emergency, you need to tell your worker at least ten
I
The County has changed your transportation payment method
days before you change your transportation arrangement.
from ______________ to ______________.
I
public transportation
I
The County has changed your other transportation (identify type):
_________ rate for each day is
____________ payment from _________to _______per_______
_________ per _____________
Here's why:
= $ ________
I
The county’s mileage rate changed effective__________________
I
The rate used to be $______ a month, now it is $ _______ a month.
your car's mileage
________ rate
I
Your mileage changed.
________ per ______________
The mileage from your home to your WTW activity each way used
to be ______ miles, now it is ______ miles.
________ miles
= $ ________
I
The public transportation rate changed effective_______________.
The rate used to be $______ a month, now it is $______ a month.
I
parking
I
Public transportation, which takes less than two hours is available
$ ________
month
school term
other
I
I
I
to get you from your home to your WTW activity.
I
Other:
I
Other:
________ Rate
Your transportation payments will be
x ________ per _______________
I
Paid in advance to you. You must turn in your proof at the end of
= $ ________
the month.
I
Paid to you at the end of the month (you did not ask for advance
payment for transportation)
I
You will not get another notice telling you when your payments end
because your activity is less than 30 days.
I
Paid to your transportation provider (who is): _________________
I
Other:
You can call your Welfare to Work/Cal- Learn worker if you think
Rules: These rules apply. You may review them at your welfare
this notice is wrong.
office: MPP Section 42-750.112, .2 and .4. Welf. & Inst. Code
11323.2, 11323.4, 11322.9
NA 822 (7/16) REQUIRED – SUBSTITUTE PERMITTED
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