Form Na 275 - Continuation Page - Overpayment Adjustment Computation - Cash Aid

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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
:
__________________________________________________________________________
Number
:
__________________________________________________________________________
Overpayment Adjustment:
NOT CAUSED
CAUSED BY
Amount to be Taken From Monthly Payment
BY COUNTY
COUNTY
ERROR
ERROR
Maximum Aid Payment (MAP)
$ ____________________
$ ___________________
Adjustment Factor
x.10
x.05
TOTAL
= ____________________
= ___________________
Your overpayment adjustment amount is:
$ ____________________
$ ___________________
____________________
___________________
[This is the highest adjustment allowed, or
the total overpayment owed, or the cash aid
Subtotal (from page 1), whichever is less.]
Rules:
These rules apply; you may review them at your
Welfare Office: MPP 44-352.41.
State Hearing:
If you think this action is wrong, you can ask for
a hearing. The back of page 1 tells how.
NA 275 (4/99) CONTINUATION PAGE
Page ______ of ______
OVERPAYMENT ADJUSTMENT COMPUTATION - CASH AID

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