Form Na 845 - Notice Of Action - Sanction And Removal Of The Other Parent'S Needs
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1
2NOTICE OF ACTION
COUNTY Of
STATE Of CAlIfORNIA
CHILD CARE DISCONTINUANCE
hEAlTh AND hUmAN SERVICES AGENCY
CAlIfORNIA DEPARTmENT Of SOCIAl SERVICES
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone:
Address :
Questions? Ask your Worker.
(ADDRESSEE)
State Hearing: If you think this action is wrong,
you can ask for a hearing. Your benefits may not
be changed if you ask for a hearing before this
action takes place. If you and the county disagree
or if you have not heard back from your worker, do
not wait to ask for a hearing. You must ask for the
hearing before a certain number of days. See the
back of this notice for more information and to find
out how to ask for a hearing.
Sanctioned Cases:
Your child care reimbursement for __________________________
will stop on _______________________.
If you are being sanctioned and need child care for activities that
NAmE Of ChIlD
are not approved by the county, you may still be eligible for Stage
DATE
hERE’S WhY:
Two child care or another state or federally funded child care and
You are not in an approved CalWORKs activity/program.
development program. If you are being sanctioned and engaged
in activities that are not approved by the county, you may ask the
You moved out of this county. We are no longer the county
county for help in transferring you to other child care for which you
processing your child care. You need to apply for child care
may be eligible. You may also apply on your own to the Resource
services in your new county of residence, so the new county
and Referral agency listed below.
can determine your eligibility for child care.
Notes
You do not have to go to the approved county welfare-to-work
activity/program right now and have chosen not to participate
as a volunteer.
You did not meet the CalWORKs program requirements. (See
notes).
You went off CalWORKs cash aid. You may be eligible for
Stage Two child care. Please call the Child Care Resource
and Referral agency listed below.
You asked that your child care reimbursements stop.
Your child is older than 12, and we do not have information
that shows your child is disabled or under court supervision to
keep getting child care.
Your child(ren) no longer need(s) child care because _______
_________________________________________________.
REASON
Your child care provider is a member of your CalWORKs/
Cal-learn assistance unit.
Your child care provider __________________________, had
NAmE
his/her application for Trustline, denied, or closed, or revoked.
Rules: These rules apply. You may review them at your welfare
Your income is $_______________ which is more than the 85%
office: CalWORKs mPP Sections 47-260, 47-430.2, 47-620.32;
percentile of the State median income limit. State law limits
Education Code Sections 8350-8353, 8357. Welfare & Institutions
Code Sections 11322.9, 11323.6, 11323.4, and 11323.8, or visit
eligibility to this income amount.
or
You are no longer eligible for post aid child care services
To see if you may qualify for other child care programs, you can contact
because__________________________________________.
the local Child Care Resource and Referral agency listed below:
REASON
Other: ____________________________________________
Name: _________________________ Telephone: ________________
You can also call your worker/case manager if you think this notice
Address: _____________________________________________
is wrong.
Page 1 of ____
NA 835 (10/17) REQUIRED fORm - SUBSTITUTES PERmITTED
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