Form Na 403a - Notice Of Action - Approval, Change Or Discontinued For Kinship - Guardians Only Page 2

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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.
DISCONTINUED
I
Your case has been discontinued.
As of ____________, the county is Discontinuing your
Kin-GAP aid of $ _____________ per month.
Here’s why:
I
You are no longer providing support
for: _________________________________________________
He/she no longer meets the age rules.
I
The youth is at least 18 years of age and does not qualify for
extended Kin-GAP.
I
The youth is at least 21 years of age.
I
The child has too much income.
I
The child has too much property. See attached page. If the
County figured that the child’s vehicle or other property was
worth more than you think it’s worth, you can give the County
proof that it is worth less. Ask the County how. If you can prove
it is worth less the child may get Kin-GAP aid.
I
The legal guardianship was terminated.
I
You did not return your completed redetermination paperwork.
I
Other: ____________________________________________
NA 403A (4/17) REQUIRED FORM - SUBSTITUTES PERMITTED
Page ____ of ____

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