Form Na 300 - Notice Of Action (Continuation Page) - Recipient - Financial Eligibility Tests
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1
2NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
RECIPIENT - FINANCIAL ELIGIBILITY TESTS
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
You are ineligible because your Total Net Countable Income (#18) is more
than your Maximum Aid Payment (#20).
Monthly Cash Aid Amount
Section A. Countable Income, Month of ___________
1.
Self-Employment Income . . . . . . . . . . . . . . . . . . . . . $ ___________
2.
Self-Employment Expenses:
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
OR
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = ___________
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 . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Net Earnings from Self-Employment (from above) . . + ___________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
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) . . . . . . . . . . . . . . . . + ____________
17. Child Support collected by the County, Except for Maximum
Family Grant child (for financial eligibility only) . . . . . + ___________
18. Total Net Countable Income . . . . . . . . . . . . . . . . . . = ___________
19. Maximum Aid Payment
Maximum Aid for ______ Persons (Assistance Unit +
Non-Assistance Unit Members) . . . . . . . . . . . . . . . .
$ __________
Special Needs (Assistance Unit + Non-Assistance Unit
Members) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
20. Maximum Aid Payment . . . . . . . . . . . . . . . . . . . . . . = ___________
Rules: These rules apply; you may review them at
your welfare office: MPP 44-207.2, SB 1041
(Chapter 47, Statutes of 2012).
State Hearing: If you think this action
is wrong, you can ask for a hearing. The
back of page 1 tells how.
NA 300 (4/13) CONTINUATION PAGE - RECIPIENT FINANCIAL ELIGIBILITY TEST
Page ____ of ____
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