Form Na 821 - Notice Of Action - Transportation Approval/denial
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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 you how.
As of _______________:
As of _______________:
The
Welfare to Work
Cal-Learn transportation:
Your transportation payment for
Job
Welfare to Work
Cal-Learn will stop.
payment
increase
you asked for is denied.
Here’s why:
Here’s why:
You are no longer attending an approved
You are already getting as much as the County can pay
Job
Welfare to Work
Cal-Learn activity.
because:
You moved out of this County.
the maximum mileage rate is: $____________________
per _______________.
You went off cash aid.
public transportation is available.
You quit your job.
Cal-Learn transportation is available.
You have been exempted from participation in
Welfare to Work
Cal-Learn.
Welfare to Work transportation is available.
You asked that transportation be stopped.
____________ transportation is available.
You did not submit your attendance forms for _____________.
You are not in an approved
Job
Welfare to Work
If this information is provided by ____________, this proposed
Cal-Learn activity.
action will be stopped.
The transportation you asked for is not needed to attend your
Other:
approved
Welfare to Work
Cal-Learn activity:
You can call your Welfare to Work/Cal-Learn worker if you think
_________________________________________________.
this notice is wrong.
Other:
You can call your Welfare to Work/Cal-Learn worker if you think
this notice is wrong.
Rules: These rules apply. You may review them at your welfare
Rules: These rules apply. You may review them at your welfare
office: MPP Sections 42-750.112, .2, .4.
office: CalWORKs Implementation Guidelines, Sections VII & XII,
Welf. & Inst. Code 11323.2, 11323.4, 11322.9
Welf. & Inst. Code 11323.2. 11323.4, 11322.9
Page 1 of ____
NA 821 (1/01) REQUIRED – SUBSTITUTE PERMITTED
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