Form Na 816 - Notice Of Action - Sanction Of Other Parent After Failed Compliance Plan
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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. 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
____________________________, as of _________________, we
hearing. You must ask for the
hearing before a certain number of
are lowering your family’s cash aid from $_______________ to
days. See the back of this notice for
$_____________ as shown on the following page. Cash aid will stop
more information and to find out
for you.
how to ask for a hearing.
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.
k
TO CONTACT THE COUNTY ABOUT GETTING BACK ON CASH AID,
CALL ______________________________________________.
The family’s other parent, _________________, may also get cash aid
again if he/she is eligible for it by contacting the county and telling them
he/she wants cash aid back; then doing what the county asks.
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 816 (3/14) REQUIRED - SUBSTITUTES PERMITTED
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