Form Na 532 - Notice Of Action (Continuation Page) - 48-Month Time Limit Discontinue - Includes Budget

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NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
48-MONTH TIME LIMIT (Continued)
Notice Date :
Case
Name
:
ADULT REACHED CalWORKS
Number
:
48-MONTH TIME LIMIT - DISCONTINUE
Section A. Net Countable Income
EXEMPT MONTHS
1.
Total Business Income . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
The following ______ months did not count toward your CalWORKs
2.
Business Expenses:
48-month time limit:
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
OR
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
Year ______ -
Jan
Feb
Mar
Apr
May
June
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = ___________
4.
Total Disability-Based Unearned Income (DBI)
July
Aug
Sept
Oct
Nov
Dec
(Assistance Unit + Non-Assistance Unit Members) . $ ___________
5.
$225 DBI Disregard (if #4 is greater than $225) . . . . - ___________
6.
Nonexempt Unearned Disability-Based Income . . . . = ___________
OR
7.
Unused DBI Disregard . . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Net Earnings from Self-Employment (from above) . . + ___________
Year ______ -
Jan
Feb
Mar
Apr
May
June
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
10. Unused Amount of $225 (from #7) . . . . . . . . . . . . . . - ___________
July
Aug
Sept
Oct
Nov
Dec
11. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
12. Earned Income Disregard 50%. . . . . . . . . . . . . . . . . . - ___________
13. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
14. Nonexempt Unearned Disability-Based Income
(from #6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
15. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
16. Other Nonexempt Income (Assistance Unit + Non-
Assistance Unit Members) . . . . . . . . . . . . . . . . . . . . . + ___________
17. Child Support collected by County, except for
Maximum Family Grant child
(for financial eligibility only) . . . . . . . . . . . . . . . . . . . . . + ___________
Section B. Net Countable Income . . . . . . . . . . . . . . . . . = ___________
1.
Maximum Aid ______ Persons
(Assistance Unit + Non-Assistance Unit Members) . . $ ___________
2.
Special Needs (Assistance Unit + Non-Assistance
Unit Members) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
3.
Net Countable Income from Section A (above) . . . . . - ___________
4.
Maximum Aid Payment . . . . . . . . . . . . . . . . . . . . . . . = ___________
Page ____ of ____
NA 532 (4/13) CONTINUATION PAGE - 48-MONTH TIME LIMIT DISCONTINUE - INCLUDES BUDGET

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