Form Na 828 - Notice Of Action - Transportation And Ancillary Exp Overpayment
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1
2STATE OF CALIFORNIA
NOTICE OF ACTION
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 payment for
:
Welfare to Work
Cal-Learn
Your payment of $____________ for _____________ has
transportation
work or training related expenses for
been adjusted effective ____________ as follows:
______________ is
$ _________ your actual advance payment for ___________.
$ _______________. This amount is less than you asked for. Your
payment limit has not changed.
–
$ _________ your actual costs for that month.
HERE’S WHY:
=
$ _________ unused advance.
You have to pay us back any money we advance to you that
$ _________ amount requested for ________________
you do not use to pay for
Welfare to Work
Cal-Learn
supportive services expenses. We subtracted that portion of
–
$ _________ unused advance.
your advance payment that was not used to pay for
=
$ _________ adjusted payment.
supportive services.
Welfare to Work
Cal-Learn
We subtracted the amount listed in your overpayment
repayment agreement dated_________________.
Your payment of $____________ for _____________ has
been adjusted effective ____________ as follows:
We subtracted the amount we figured we need to take to
adjust your overpayment. We told you about this in your
$ _________ amount you asked for.
overpayment notice dated _________________.
–
$ _________ amount collected because of an overpayment.
Other:
=
$ _________ adjusted payment.
Your
transportation payment
work or training related
expenses payment is figured on this notice.
Call your worker if this adjusted payment means you will not be
able to stay in your
Welfare to Work
Cal-Learn
activity, or
Mileage can be paid only if there is no public transportation
if you will not be able to accept a job.
available, or it cost the same or less than public transportation.
Public transportation is available when it takes two hours or less
round trip to get you from your home to your activity on time. You
You can also call your Welfare to Work/Cal-Learn worker if you
cannot count time to go to and from your child’s school or child
think this notice is wrong.
care. If you drive your car even though public transportation is
available, you will be paid at the public transportation rate or the
mileage rate, whichever is lower.
Rules: These rules apply. You may review them at your welfare
office: CalWORKs Implementation Guidelines, Sections VII &
XII, Welf. & Inst. Code 11323.2, 11323.4, 11322.9
Page 1 of ____
NA 828 (7/99) REQUIRED – SUBSTITUTE PERMITTED
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