Form Na 278 - Discontinue/suspend - Optional Persons Transfer Of Property

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NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date
:
:
Case
Name
:
Number
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 how. Your benefits may not be changed if you
ask for a hearing before this action takes place.
Fair Market Value . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
Amount Received . . . . . . . . . . . . . . . . . . . . . . . . – ___________
(A) Transfer of Property Amount . . . . . . . . . . = ___________
Family Needs
Basic Need for ______ Persons . . . . . . . . . $ ___________
Special Needs . . . . . . . . . . . . . . . . . . . . . . . + ___________
(B) Family Needs . . . . . . . . . . . . . . . . . . . . . . . = ___________
Optional Person(s) Needs
Basic Need for ______ Persons . . . . . . . . . $ ___________
Special Needs . . . . . . . . . . . . . . . . . . . . . . . + ___________
(C) Optional Person(s) Needs . . . . . . . . . . . . = ___________
Differential
Family Needs . . . . . . . . . . . . . . . . . . . . . . .
___________
Optional Person(s) Needs . . . . . . . . . . . . . . - ___________
(D) Differential . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Ineligibility for Optional Persons
Your transfer of property amount (A)
minus the differential (D)
divided by the optional person(s) needs (C)
equals the number of ineligible months: . . .
___________
(# OF MONTHS)
Rules: These rules apply; you may review them at your
Welfare Office: MPP
Page _____ of _____
NA 278 (1/00) DISCONTINUE/SUSPEND - OPTIONAL PERSONS TRANSFER OF PROPERTY

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Parent category: Legal
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