Form Na 403a - Notice Of Action - Approval, Change Or Discontinued For Kinship - Guardians Only

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STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION - APPROVAL,
Notice Date:
Case Name:
CHANGE OR DISCONTINUED
Number:
For Kinship - Guardians Only
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.
APPROVAL
I
The County has approved your Kin-GAP aid.
As of ____________, the county is Approving Kin-GAP aid
of $ _____________ per month.
This aid is for: ________________________________________.
CHANGE
As of ____________, the county is Changing your Kin-GAP aid
from $ ___________ to $ ___________.
This aid is for: ________________________________________.
Here’s why: Your rate is based on a level of care determination as
defined in AB 403 and WIC section 11461.
I
Your case had a rate increase.
I
Your case had a rate decrease.
I
Your case has been issued an Infant Supplemental Payment.
I
Your case has been issued a Supplemental Care Increment.
I
The child has countable income.
_____________________ for ____________________________
(Income Type)
(Child’s Name)
of $ ____________ is effective ____________.
This is counted as ______________________income in the
Kin-GAP budget calculation.
I
Other: ____________________________________________
I
Due to funding requirements, you may receive multiple checks
for this benefit month. The sum of these checks will be equal to
the amount listed above.
NA 403A (4/17) REQUIRED FORM - SUBSTITUTES PERMITTED
Page ____ of ____

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