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
EXEMPT MONTHS
Monthly Cash Aid Amount
Section A. Countable Income, Month of ___________
The following ______ months did not count toward your CalWORKs
1.
Self-Employment Income . . . . . . . . . . . . . . . . . . . . . . $ ___________
48-month time limit:
2.
Self-Employment Expenses:
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
OR
Year ______ -
Jan
Feb
Mar
Apr
May
June
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = ___________
July
Aug
Sept
Oct
Nov
Dec
4.
Total Disability-Based Unearned Income (DBI)
(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 . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Year ______ -
Jan
Feb
Mar
Apr
May
June
8.
Net Earnings from Self-Employment (from above) . . + ___________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
July
Aug
Sept
Oct
Nov
Dec
10. Unused Amount of $225 (from #7) . . . . . . . . . . . . . . - ___________
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) . . . . . . . . . . . . . . . . . . . . . + ___________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Section B. Your Cash Aid, Month of ____________
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.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
5.
Maximum Aid ______ Persons (Assistance Unit only)
(Excluding MFG, or Penalized Persons) . . . . . . . . . . $ ___________
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + ___________
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Full Month Aid Subtotal
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = ___________
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = ___________
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - ___________
Other Penalties . . . . . . . . . . . . . . . . . . - ___________
Overpayment . . . . . . . . . . . . . . . . . . . . - ___________
Cal-Learn Penalties . . . . . . . . . . . . . . . - ___________
School Bonus ($100 or $500) . . . . . . . + ___________
11. Monthly Cash Aid Amount
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
Page ____ of ____
NA 531 (4/13) CONTINUATION PAGE - 48-MONTH TIME LIMIT - INCLUDES BUDGET