NOTICE OF ACTION
STATE OF CALIFORNIA
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
benefits may not be changed if you ask for a hearing
before this action takes place.
A.
Items:
VALUE
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
____________________________________
__________
B.
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
1500
C.
Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
– _________
D.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
= _________
E.
Number of Sponsored Non-Citizens on CalWORKs
÷ _________
F.
Divide D by E . . . . . . . . . . . . . . . . . . . . . . . . .
= _________
The amount in F is to be included in the sponsored non-citizen’s property
limits for CalWorks.
Medi-Cal: This notice does NOT change or stop Medi-Cal
benefits. If there is a change in your Medi-Cal benefits, you will
receive another notice. Keep your plastic Benefits
Identification Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP
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NA 216 (11/99) SPONSORED NON-CITIZENS (PROPERTY)