Form Na 1277 - Notice Of Action Approved Relative Caregiver (Arc) Overpayment
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
APPROVED RELATIVE CAREGIVER (ARC)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
OVERPAYMENT
Notice Date:
Case Name:
Case Worker Number:
Case Worker Name:
Case Number:
Telephone:
Address:
(ADDRESSEE)
For Approved Relative Caregivers participating in the
2) Sign a written repayment agreement. You must contact the
worker at the top of this form to discuss the terms of a written
Approved Relative Caregiver Funding Option Program
payment agreement..
(ARC Program):
If you have any questions regarding the overpayment computation
This is to inform you that you were overpaid ARC Program benefits
or repayment arrangements, please contact the case worker at the
top of this form.
for
(NAME OF CHILD)
Relevant Law: Welfare and Institutions Code sections 11461.3
for the month(s ) of
to
and 11466.24; MPP sections 22-009, 45-304, 45-305, and 45-306.
(MM/DD/YYYY)
(MM/DD/YYYY)
Total amount you received: $
Insert overpayment calculations and substantiation of time
periods by month as required in regulation. See Manual of
Total amount you should have received: $
Policies and Procedures (MPP) section 45-305. Attach a page if
Total amount of Overpayment: $
additional space is needed.
Date of Discovery:
(MM/DD/YYYY)
(Collection is permitted if demand is made within one year
of discovery.)
You are required to repay the overpayment
amount of $
.
Reason for the overpayment:
From
(date) the child/youth was not
I
residing in your home, and you failed to report that to your
county social worker and you received payments for him/her
that you were not entitled to.
I
Other:
By law, we can collect ARC Program overpayments if the approved
relative caregiver caused the overpayment. We cannot require you
to repay the overpayment if you meet an exception. Exceptions to
repayment are:
The overpayment was caused by county administrative error,
G
OR
Neither the county nor the approved relative caregiver knew of
G
or contributed to the cause of the overpayment.
The minor’s absence was temporary and the funds were used
G
to maintain the home for his/her return or used to support
his/her needs.
If you disagree with the reason for the overpayment or the
amount of the overpayment, you may request a hearing. Please
see the following page for hearing instructions.
If you agree with the reason for the overpayment and the amount of
the overpayment, you must do one of the following within 90
calendar days from the day the county gave or mailed you this
notice:
1) Make a one-time payment of the total amount.
Please pay by check or money order, made payable to:
Send to:
NA 1277 (1/16) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE 1 OF ______
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