Form 403 - Notice Of Action - Approval, Change Or Discontinued Page 2
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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.
DISCONTINUED
Your case has been discontinued.
As of ____________, the county is Discontinuing your
Foster Care aid of $ _____________ per month.
Here’s why:
You are no longer providing foster care
for: ________________________________________________
The child’s dependency case has been dismissed.
He/she is no longer living in your home/facility. The County will
stop paying for Foster Care from the day the child leaves your
home/facility. He/she no longer meets the age rules.
The youth is at least 18 years of age and does not qualify for
extended foster care.
The youth is at least 21 years of age.
The child has too much income.
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 Foster Care aid.
The legal guardianship was terminated.
You moved out of the State of California.
You did not return your completed redetermination paperwork.
Other: ___________________________________________
NA 403 (4/17) REQUIRED FORM - SUBSTITUTES PERMITTED
Page ____ of ____
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