Form Na 215 - Notice Of Action (Continuation Page) - Sponsored Non-Citizens - Deemed Income

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NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date
__________________________________________________________________________
Case
Name
__________________________________________________________________________
SPONSORED NON-CITIZENS
Number
__________________________________________________________________________
(DEEMED INCOME)
A.
Earned Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
___________
B.
Less 20% of A (Not to exceed $175) . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
___________
C. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=
___________
D.
Unearned Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
+
___________
E.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=
___________
F.
Less MBSAC for sponsor and for tax dependents living
inside the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
___________
G. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=
___________
H. Less amounts paid by the sponsor for tax dependents
living outside the household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
___________
I.
Less child/spousal support paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
___________
J.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=
___________
K.
Number of Sponsored Non-Citizens in the Assistance Unit . . . . . . . . . .
÷
___________
L.
Divide J by K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
=
___________
Rules:
These rules apply; you may review them at your welfare
office: MPP 44-133.10
State Hearing:
If you think this action is wrong, you can ask for
a hearing. The back of page 1 tells how.
NA 215 (1/00) CONTINUATION PAGE - SPONSORED NON-CITIZENS (DEEMED INCOME)
Page _________ of ________

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