Form Na 301 - Continuation Page - Applicant Financial Eligibility Test
Download a blank fillable Form Na 301 - Continuation Page - Applicant Financial Eligibility Test in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Na 301 - Continuation Page - Applicant Financial Eligibility Test with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
APPLICANT - FINANCIAL ELIGIBILITY TEST
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
You are ineligible because your Net Countable Income is more than
your Family Needs.
Family’s Total Earned Income (Assistance Unit +
Non-Assistance Unit Members) . . . . . . . . . . . . . $ __________
$90 Disregard for each employed person . . . . . . . . . - __________
Other Nonexempt Income (Assistance Unit +
Non-Assistance Unit Members) . . . . . . . . . . . . . + __________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . = __________
Family Needs
Basic Need for ______ Persons (Assistance Unit +
Non-Assistance Unit Members) . . . . . . . . . . . . . $ __________
Special Needs (Assistance Unit + Non-Assistance
Unit Members) . . . . . . . . . . . . . . . . . . . . . . . . . . + __________
Family Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = __________
Rules:
These rules apply; you may review them at your welfare office:
MPP 44-207.1
State Hearing: If you think this action is wrong, you can ask for a
hearing. The back of page 1 tells how.
NA 301 (1/99) CONTINUATION PAGE - APPLICANT FINANCIAL ELIGIBILITY TEST
Page ____ of ____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal