Form Na 820 - Notice Of Action - Transportation Approval
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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.
As of _______________until _______________, the County has
public transportation
approved your transportation for:
Welfare to Work
Cal-Learn
_____
rate
The most we can pay is $ _______for a total of _____ miles
X
_____
per ________________
per ________.
= $ _____
The County has approved $ __________ per ____________
based on public transportation rates.
The County has approved bus passes or tickets for a total of
your car’s mileage
__________ per __________.
The County has approved the cost of another form of
_____
rate
transportation:
X
_____
per ________________
__________ for a total of $ __________ per __________.
The County will provide you with
Welfare to Work
X
_____
miles
Cal-Learn transportation.
= $ _____
The County will only pay for transportation while you are attending
your approved
Job
Welfare to Work
Cal-Learn activity:__________________________________ .
parking
The County may continue to pay for transportation for up to
$ _____
month
school term
other
the first 12 months after you have left aid if you have a job.
We will pay only if you need it to keep your job and you
cannot get the transportation costs from somewhere else.
Other: ____________
Your transportation payment limit is figured on this notice.
Mileage can be paid only if there is no public transportation
available, or it costs the same or less than public transportation.
__________ rate
Public transportation is available when it takes two hours or less
round trip to get you from your home to your activity on time. You
x _________ per __________
cannot count time to go to and from your child’s school or child
care. If you drive your car even though public transportation is
=$ ________
available, you will be paid at the public transportation rate or the
mileage rate, whichever is lower.
Your transportation payments will be
Advanced to you
Paid back to you
Paid to your transportation provider
Other:
YOU MUST TELL US BEFORE YOU CHANGE YOUR
TRANSPORTATION ARRANGEMENTS EXCEPT IN AN
EMERGENCY OR WE MAY NOT BE ABLE TO APPROVE AND
PAY FOR THE NEW ARRANGEMENTS.
Because your activity is less than 30 days, you will not get
another notice telling you when your payments end.
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
office: MPP Sections 42-750.112, .2 and .4. Welf. & Inst. Code
11323.2, 11323.4, 11322.9
NA 820 (1/01) REQUIRED – SUBSTITUTE PERMITTED
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