Form Na 817 - Notice Of Action - Sanction Of Participant After Failed Compliance Plan
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1
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.
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
ask for the hearing before a certain
number of days. See the back of this
____________________________, as of ___________________, we
notice for more information and to
are changing your family’s cash aid from $____________ to
find out how to ask for a hearing.
$_____________ as shown on the following page.
We are lowering your family’s cash aid because you did not have a
good reason for not doing what you agreed to do in the compliance
plan that you signed. You agreed to:
_______________________________________________________
_______________________________________________________
We will not pay for transportation, or work- or training-related
expenses while you are off cash aid. We may pay for child care, if you
work or attend school.
HOW TO GET YOURSELF BACK ON CASH AID
Your family’s cash aid is being lowered because you did not do what
we asked you to do and you are being removed from the Assistance
Unit. If your family’s cash aid is lowered, you can get your portion of
the cash aid back if you are eligible for it by contacting the county and
telling them you want your cash aid back; then doing what the county
asks.
TO CONTACT THE COUNTY ABOUT GETTING BACK ON CASH
AID, CALL ____________________________________ .
DO YOU NEED FREE LEGAL HELP? You can get free help with this
problem from:
Local Legal Aid Office: (
)
_______________________________________________________
State Welfare Rights Organization: (
)
_______________________________________________________
CalFresh: If the failure to meet Welfare-to-Work requirements also
causes a CalFresh penalty, you may not be able to get CalFresh. 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 817 (3/14) REQUIRED - SUBSTITUTES PERMITTED
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