Form Na 531 - Notice Of Action (Continuation Page) - 48-Month Time Limit - Adult Reached Calworks - Includes Budget

Download a blank fillable Form Na 531 - Notice Of Action (Continuation Page) - 48-Month Time Limit - Adult Reached Calworks - Includes Budget in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Na 531 - Notice Of Action (Continuation Page) - 48-Month Time Limit - Adult Reached Calworks - Includes Budget with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go