Form Na 691 - Notice Of Denial - Cash Assistance Program For Immigrants (Capi)
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1
2NOTICE OF DENIAL
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM
FOR IMMIGRANTS (CAPI)
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. The back of this page tells you how.
Your benefits may not be changed if you ask for a
hearing before this action takes place.
Comments:
Your application for the Cash Assistance Program for
Immigrants (CAPI) dated ____________ has been denied
(month/day/year)
because:
Your citizenship/immigration status does not meet CAPI
requirements. (MPP 49-020)
Your income of $____________________, which may
include income deemed from your sponsor, is more than
the allowable limit. (MPP 49-035)
Your resources, which may include resources deemed
from your sponsor, exceed the allowable limit of $2,000
for an individual or $3,000 for a couple. (MPP 49-040)
Failure to provide proof that you applied for SSI benefits,
or have taken all necessary steps to obtain SSI benefits.
(MPP 49-030)
Your SSI benefits have been approved; you cannot
receive both SSI benefits and payments under CAPI.
(MPP 49-030)
Failure to cooperate with the county application process
(see comments). (MPP 49-015.1)
You are a resident of a public institution.
(MPP 49-010.21)
You are not a California resident. (MPP 49-010.14)
The county has information that the applicant is now
deceased. (MPP 49-060.33)
You are not age 65 or older, blind, or disabled.
(MPP 49-025)
You have voluntarily withdrawn your application.
You are outside of the United States for an entire
month. (MPP 49-010.24)
Other._______________________________________.
Rules: These rules apply; you may review them at your welfare
office: Welfare and Institutions Code, Division 9, Par t 6,
Chapter 10.3, Sections 18937 through 18944; MPP Sections
49-001 through 49-070.
Page 1 of ____
NA 691 (11/06)
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