Form Na 692 - Notice Of Change - Cash Assistance Program For Immigrants (Capi) Page 2
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4State of California – Health and Human Services Agency
California Department of Social Services
Your SSI benefits have been approved; you may not receive both SSI benefits and payments
under CAPI. (MPP Section 49-030)
You have failed to cooperate with the county (see note below and comments section).
(MPP Section 49-060.1(d))
You are a resident of a public institution. (MPP Section 49-010.21)
You are not a California resident. (MPP Section 49-010.14)
The county has information that the recipient is now deceased. (MPP Section 49-060.33)
You are no longer blind or disabled. (MPP Section 49-025)
You asked us to stop your CAPI payments. (MPP Section 49-060.35)
You are outside the United States for an entire month. (MPP Section 49-010.24)
You have violated a condition of probation or parole, or you are a fleeing felon.
(MPP Section 49-060.1(i))
Other _______________________________________________________________________
Comments:
Rules: These rules apply; you may review them (MPP Sections 49-001 through 49-070) at your
welfare office.
Note: If, within 12 months of suspension, you provide the county with evidence that you re-qualify for
CAPI, your CAPI benefits will be reinstated. If you don’t, your CAPI case will be terminated. If you
later decide to reapply for CAPI, you will be required to complete a new application form and start
over.
REPORTING RESPONSIBILITIES
The amount of your CAPI payment is based on all the information we received. You must tell the
county every time there is any change, including changes in income, resources or living arrangements
for yourself, or your spouse, parent or child who lives with you, or your sponsor and his or her spouse
regardless of where they live.
You must tell us about any change within 10 days of the change. Remember, a change may make your
CAPI monthly payment bigger or smaller. You may need to pay back any overpayments you receive.
NA 692 (12/17)
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