Form Na 274b - Continuation Page Overpayment Computations (For 10/1/89 To 8/31/91)

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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 Amount Owed
Worker
(For Overpayments Occurring From 10-1-89 to 8-31-91)
Number
:_____________________________________________________________________________
Overpayment 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 and all the cash aid you got is an
overpayment. The amount of your overpayment is figured below.
B
Net Countable Income
Total Earned Income
$
______________
______________
______________
______________
______________
Work Expense Disregard
–
______________
______________
______________
______________
______________
$30 Disregard
–
______________
______________
______________
______________
______________
1/3 Disregard
–
______________
______________
______________
______________
______________
Subtotal
=
______________
______________
______________
______________
______________
Dependent Care Disregard
–
______________
______________
______________
______________
______________
Other Countable Income (List Sources)
_______________________________
+
______________
______________
______________
______________
______________
_______________________________
+
______________
______________
______________
______________
______________
Court Ordered Child/Spousal Support Paid
–
______________
______________
______________
______________
______________
Unmet Needs of Ineligible Alien Child(ren)
–
______________
______________
______________
______________
______________
Net Countable Income
=
______________
______________
______________
______________
______________
C Correct Cash Aid Payment
Basic Aid Amount (# persons) $ Amount
(
)
(
)
(
)
(
)
(
)
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Net Countable Income
–
______________
______________
______________
______________
______________
Correct Cash Aid Amount
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
D Overpayment
Cash Aid Paid to You
$
______________
______________
______________
______________
______________
Correct Cash Aid Amount
–
______________
______________
______________
______________
______________
Subtotal A
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Cash Aid Paid to You
$
______________
______________
______________
______________
______________
Support Payments Collected for You
–
______________
______________
______________
______________
______________
Subtotal B
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Amount of Overpayment for Each Month
=
______________
______________
______________
______________
______________
(Lesser of Subtotal A or B)
TOTAL OVERPAYMENT (All Months)
$ ______________
Rules: These rules apply; you may review them at your
Welfare Office: MPP 44-352.12
State Hearing: If you think this action is wrong, you can ask
for a hearing. The back of Page 1 tells how
NA 274 B (4/99) CONTINUATION PAGE - OVERPAYMENT COMPUTATIONS (FOR 10-1-89 TO 8-31-91)
Page____ of ____

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