Form Na 791 - Notice Of Action - Approval/denial/change Page 2
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An overpayment of $_______________ had occurred for the period of _______________ to_______________ :
MONTH/DATE OF
AMOUNT SHOULD
MONTH/DATE OF
AMOUNT SHOULD
PAYMENT
AMOUNT RECEIVED
HAVE RECEIVED
PAYMENT
AMOUNT RECEIVED
HAVE RECEIVED
You were overpaid because you failed to report:
I
I
You were no longer supporting your child
A.
You were no longer legally responsible for your child
I
B.
I
Your child has married
a.
I
Your child has enlisted and is on active duty in the military
b.
Your parental rights have been terminated
c.
I
I
You may have committed fraud in your application for or reassessment of the AAP benefits, and as a result have received
checks/deposits to which your child was not entitled to receive.
Description of the alleged fraud:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
The county shall not demand overpayment collection when the overpayment was due to county error.
Comments:
Regulations: This action is required by the following state regulations which are available for review at
the Adoption Agency: California Code of Regulations Title 22, Division 2, Chapter 3, Subchapter 7,
Articles 1-10, Sections 35325-35352.2
State Hearing:
If you are dissatisfied with this action, your aid may continue unchanged if you ask for
a State Hearing before the effective date of the action. Read the back for important information about
your right to appeal this action.
NA 791 (11/16)– REQUIRED FORM
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