NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date : ____________________________________________________________________________
Case
Name
: ____________________________________________________________________________
Overpayment Amount Owed
Number
: ____________________________________________________________________________
(For Overpayments Occurring on or after 7-1-2011)
Worker
Name
: ____________________________________________________________________________
Number
: ____________________________________________________________________________
Overpayment Month and Year
Section A. Countable Income, Month of ___________
________
________
________
1.
Total 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 (up to $112) . . . . . . . . . . . . . . = ___________
________
________
________
8.
Net Earnings from Self-Employment (from above) . . + ___________
________
________
________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + ___________
10. Unused Amount of $225 (from #7) or $112
________
________
________
(whichever is less) . . . . . . . . . . . . . . . . . . . . . . . . . . . - ___________
________
________
________
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) . . . . . . . . . . . . . . . . . . . . . + ___________
________
________
________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Section B. Your Cash Aid, Month of ____________
1.
Maximum Aid ______ Persons
________
________
________
(Assistance Unit + Non-Assistance Unit Members) . . $ ___________
2.
Special Needs (Assistance Unit + Non-Assistance
________
________
________
Unit Members) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + ___________
________
________
________
3.
Net Countable Income from Section A (above) . . . . . - ___________
________
________
________
4.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
5.
Maximum Aid ______ Persons (Assistance Unit only)
________
________
________
(Excluding MFG, or Penalized Persons) . . . . . . . . . . $ ___________
________
________
________
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + ___________
________
________
________
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = ___________
8.
Full Month Aid Subtotal
________
________
________
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = ___________
________
________
________
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = ___________
________
________
________
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - ___________
________
________
________
Other Penalties . . . . . . . . . . . . . . . . . . - ___________
________
________
________
Overpayment . . . . . . . . . . . . . . . . . . . . - ___________
________
________
________
Child-Only Grant Cut (5%, 10%, 15%) . - ___________
________
________
________
School Bonus ($100 or $500) . . . . . . . + ___________
11. Monthly Cash Aid Amount
________
________
________
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
12. Overpayment
________
________
________
Cash Aid Paid to You . . . . . . . . . . . . . . $ ___________
Correct Cash Aid Amount with
________
________
________
Adjustments . . . . . . . . . . . . . . . . . . . - ___________
________
________
________
Subtotal = ___________
________
________
________
13. Cash Aid Paid to You . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
________
________
________
Support Payments Collected for You . . . . . . . . . - ___________
________
________
________
Subtotal = ___________
14. Amount of Overpayment for Each Month
________
________
________
(Lesser of Subtotal 12 or 13) . . . . . . . . . . . . . . = ___________
TOTAL OVERPAYMENT (All Months) $____________
Rules: These rules apply; you may review them at your Welfare Office: MPP 44-352, SB 72 (Chapter 8, Statutes of 2011).
State Hearing: If you think this action is wrong, you can ask for a hearing. The back of Page 1 tells how.
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NA 274F (6/11) CONTINUATION PAGE - OVERPAYMENT COMPUTATIONS (FOR 7-1-2011)