Form Na 214 - Notice Of Action - Discontinue/suspend - Transfer Of Property
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1
2NOTICE 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 of transferred property . . . . . . $ ___________
Other countable property . . . . . . . . . . . . . . . . . . + ___________
Total Property Value . . . . . . . . . . . . . . . . . . . . . = ___________
Property Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . – ___________
(A) Excess Property Amount . . . . . . . . . . . . . = ___________
Fair Market Value of transferred property . . . . . . $ ___________
Amount actually received . . . . . . . . . . . . . . . . . . – ___________
(B) Difference . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Family Needs
Basic Need for______Persons . . . . . . . . . . $ ___________
Special Needs . . . . . . . . . . . . . . . . . . . . . . . + ___________
(C) Family Needs . . . . . . . . . . . . . . . . . . . . . . . = ___________
Lesser amount of (A) and (B) . . . . . . . . . . . . . . $ ___________
Divide by (C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÷ ___________
Period of Ineligibility . . . . . . . . . . . . . . . . . . . . = ___________
(# OF MONTHS)
(rounded down to nearest whole number)
Medi-Cal: This notice does NOT change or stop Medi-Cal
benefits. If there is a change in your Medi-Cal benefits, you will
receive another notice. Keep your plastic Benefits
Identification Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP 42-207 and 42-221.
NA 214 (4/00) DISCONTINUE/SUSPEND - TRANSFER OF PROPERTY
Page _____ of _____
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Parent category: Legal