Form Na 818 - Notice Of Action - Taking You Out Of Welfare To Work
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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.
Your benefits may not be changed if
you ask for a hearing before this
action takes place. If you and the
county disagree or if you have not
heard back from your worker, do not
wait to ask for a hearing. You must
__________________ _________, as of _____________ , we are
ask for the hearing before a certain
taking you out of Welfare-to-Work.
number of days. See the back of this
notice for more information and to
We will not change your cash aid grant amount.
find out how to ask for a hearing.
We are taking you out of Welfare-to-Work because you did not
have a good reason for not doing what you agreed to do in the
DO YOU NEED FREE LEGAL HELP? You can get free help with
compliance plan that you signed. You agreed to: ______________
this problem from:
____________________________________________________
Local Legal Aid Office: (
)
We will not pay transpor tation, or work- or training-related
expenses while you are out of Welfare-to-Work. We may pay for
child care, if you work or attend school.
_____________________________________________________
State Welfare Rights Organization: (
)
You may be able to get in Welfare-to-Work again at a later date. To
find out when you may be able to participate again and what you
_____________________________________________________
must do, contact your Welfare-to-Work worker at the telephone
number listed below.
Welfare-to-Work Worker’s Name: __________________________
Telephone Number: ____________________________________
CalFresh: If the failure to meet Welfare-to-Work requirements also
causes a CalFresh penalty, you may not be able to get CalFresh
benefits. If there is a CalFresh penalty, you will get another notice
telling you how long your CalFresh benefits will be stopped.
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:
CalWORKs MPP § 42-712
(exemptions); 42-713 (good cause); 42-721 (noncompliance and
good cause). CalFresh MPP § 63-407.521. You may review these
rules at your welfare office.
Page 1 of ____
NA 818 (3/14) REQUIRED FORM - SUBSTITUTE PERMITTED
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