Form Na 213 - Deny - Financial Eligibility

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NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
DENY - FINANCIAL ELIGIBILITY
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.
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) . . . . . . . . . . . . . . . . . +
(A) Net Countable Income . . . . . . . . . . . . . . . . . . . =
Family Needs
Basic Need for ______Persons
(Assistance Unit + Non-Assistance Unit Members) . $
Special Needs (Assistance Unit + Non-Assistance
Unit Members ) . . . . . . . . . . . . . . . . . . . . . . . . . +
(B) Family Needs . . . . . . . . . . . . . . . . . . . . . . . . . . =
Medi-Cal: This Notice of Action does NOT change or stop Medi-Cal
benefits. Keep your plastic Benefits Identification Card(s).
Rules: These rules apply; you may review them at your welfare
office: MPP 44-207.1.
NA 213 (1/99) DENY - FINANCIAL ELIGIBILITY

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