Form Na 692 - Notice Of Change - Cash Assistance Program For Immigrants (Capi)
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4State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF CHANGE
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
County of:
(ADDRESSEE)
Notice Date:
Case Name:
Case Number:
Worker Name:
Worker Number:
Telephone Number:
Address:
Questions? Ask your worker.
State Hearing: If you think this action is wrong, you can ask for a hearing. The pages that
follow tell you how. Your benefits may not be changed if you ask for a hearing before this
action takes place.
The changes that apply to you are checked off below.
REINSTATEMENT OF SUSPENDED BENEFITS
Effective _________________, your suspended CAPI payments have been reinstated. Your monthly
CAPI payment is $_____________.
CHANGE IN BENEFITS
Effective _________________, your monthly CAPI payments are changed from $____________ to
$___________ because:
Your income changed or the income of your spouse, parent or sponsor changed.
Your marital status changed. (MPP Sections 49-035, 49-050)
Your living arrangements changed. (MPP Section 49-050)
You were overpaid (see comments). (20 CFR 416.537)
Other _______________________________________________________________________
SUSPENSION OR TERMINATION
Effective ___________________, your CAPI payments are
suspended
terminated because:
Your CAPI benefits have been suspended for 12 months.
Your citizenship/immigration status does not meet CAPI requirements. (MPP Section 49-020)
Your income of $___________, which may include income deemed from your sponsor, is more
than the allowable limit. (MPP Section 49-035)
Your resources, which may include resources deemed from your sponsor, exceeded the
allowable limit of $2,000 for an individual or $3,000 for a couple. (MPP Section 49-040)
You failed to provide proof that you applied for all possible benefits (including SSI) or you failed
to take all necessary steps to obtain those benefits. (MPP Sections 49-030, 49-060.1(j))
Page 1 of ___
NA 692 (12/17)
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