Form Temp Na 1231 - Notice Of Action
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1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date : ____________________________________________________________________________
Case
Underpayment Amount Owed
Name
: ____________________________________________________________________________
(For Underpayments Occurring Prior to 1/1/98)
Number
: ____________________________________________________________________________
Underpayment Month and Year:
______________
______________
______________
______________
______________
A
Family Gross Income
____________________________
$
______________
______________
______________
______________
______________
____________________________
+
______________
______________
______________
______________
______________
Total Gross Income 1
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Basic Need for _____ Persons
$
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Total Needs
=
______________
______________
______________
______________
______________
X
1.85
185% of Needs 2
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
If 1 is larger than 2 , you were not eligible in that month so no underpayment occurred.
B
Net Countable Income
Total Earned Income
$
______________
______________
______________
______________
______________
Work Expense Disregard
–
______________
______________
______________
______________
______________
$30 and 1/3 Disregard (Assistance Unit only)
–
______________
______________
______________
______________
______________
Subtotal
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Dependent Care Disregard
(Assistance Unit only)
–
______________
______________
______________
______________
______________
Other Countable Income (List Sources)
_______________________________
+
______________
______________
______________
______________
______________
_______________________________
+
______________
______________
______________
______________
______________
Court Ordered Child/Spousal Support Paid
for Persons Not Living in the Home
–
______________
______________
______________
______________
______________
Support Paid to Other(s) Not Living in the
Home Claimed as Federal Tax Dependent
(Non-Assistance Unit Only)
–
______________
______________
______________
______________
______________
Net Countable Income
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
C Correct Cash Aid Payment
Basic Need Amount (# persons)
$
(
)
(
)
(
)
(
)
(
)
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Net Countable Income
–
______________
______________
______________
______________
______________
Subtotal A
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Maximum Aid Payment (MAP)
$
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Subtotal B
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Correct Cash Aid Amount
(Lesser of Subtotal A or B)
$
______________
______________
______________
______________
______________
D Underpayment
Correct Cash Aid Amount
$
______________
______________
______________
______________
______________
Cash Aid Paid to You
–
______________
______________
______________
______________
______________
Underpayment
Subtotal C
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Total Underpayment (Subtotal C-All Months)
$ ______________
TOTAL RETROACTIVE BENEFITS (All Months)
$ ______________
______________
Rules: These rules apply; you may review them at your
Welfare Office:
State Hearing: If you think this action is wrong, you can ask for
a hearing. The back of Page 1 tells how.
Page 2 of 2
TEMP NA 1231 (5/02) CONTINUATION PAGE - UNDERPAYMENT COMPUTATION PRE 1/1/98 - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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