Form Na 200 - Notice Of Action - Multipurpose - Incl Budget
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
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.
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) . . . . . . . . . . . . . . . . . . . . . + ___________
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = ___________
Medi-Cal: This notice DOES NOT change or stop Medi-Cal Benefits.
5.
Maximum Aid ______ Persons (Assistance Unit only)
Keep using your plastic Benefits Identification Card(s). You will get
(Excluding MFG, or Penalized Persons) . . . . . . . . . . $ ___________
another notice telling you about any changes to your health benefits.
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + ___________
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = ___________
CalFresh: This notice DOES NOT stop or change your CalFresh
8.
Full Month Aid Subtotal
benefits. You will get a separate notice telling you about any changes to
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = ___________
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = ___________
your CalFresh benefits.
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - ___________
Other Penalties . . . . . . . . . . . . . . . . . . - ___________
Receiving Medi-Cal and/or CalFresh only DOES NOT count against
Overpayment . . . . . . . . . . . . . . . . . . . . - ___________
your cash aid time limits.
Cal-Learn Penalties . . . . . . . . . . . . . . . - ___________
School Bonus ($100 or $500) . . . . . . . + ___________
Rules: These rules apply; you may review them at your welfare
11. Monthly Cash Aid Amount
office: MPP 44-100; 44-314; 44-315; SB 1041 (Chapter 47,
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ ___________
Statutes of 2012).
Page 1 of ____
NA 200 (4/13) MULTIPURPOSE — INCL BUDGET - REQUIRED FORM - SUBSTITUTE PERMITTED
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