Form 403 - Notice Of Action - Approval, Change Or Discontinued
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3STATE 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 Resource Families, including homes certified by a Foster
Worker Name:
Family Agency, County Approved Relative Homes, Non-Relative
Number:
Extended Family Members, Foster Family Homes, Non-Related
Telephone:
Legal Guardians, Intensive Treatment Foster Care and/or
Address:
Intensive Services Foster Care, Group Homes and Short-Term
Residential Therapeutic Programs
(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
The County has approved your Foster Care aid.
As of ____________, the county is Approving your Foster Care
aid of $ _____________ per month.
This aid is for: _______________________________________.
CHANGE
As of ____________, the county is Changing your Foster Care 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.
Your case had a rate increase.
Your case had a rate decrease.
Your case has been issued an Infant Supplemental Payment.
Your case has been issued a Supplemental Care Increment.
The child has countable income.
__________________ for ______________________________
of $ ____________ is effective ____________.
This is counted as ______________________ income in the
Foster Care budget calculation.
Other: ___________________________________________
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 403 (4/17) REQUIRED FORM - SUBSTITUTES PERMITTED
Page ____ of ____
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