Form Na 1261 - Notice Of Action - Form And Instructions - For Group Homes, Short-Term Residential Treatment Centers, Foster Family Agencies, Transitional Housing Placement-Plus Foster Care And Transitional Housing Placement Program
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FORM AND INSTRUCTIONS -
FOR GROUP HOMES, SHORT-TERM RESIDENTIAL
(4) Notice Date:
TREATMENT CENTERS, FOSTER FAMILY AGENCIES,
(5) Case Name:
TRANSITIONAL HOUSING PLACEMENT-PLUS FOSTER
(6) Case Worker
Number:
CARE AND TRANSITIONAL HOUSING PLACEMENT
(7) Case Worker
PROGRAM
Name:
(8) Case Number:
(1) Name:
(9) Telephone:
(2) Address:
(3) City, State Zip:
(10) Address:
Questions? Ask your Worker.
For Group Homes, Short-Term Residential Treatment Centers,
(19) Insert overpayment calculations and substantiation of time
Foster Family Agencies, Transitional Housing Placement-Plus
periods by month as required in regulation. See MPP Section 45-
Foster Care And Transitional Housing Placement Program
305. Attach a page if additional space is needed.
This is to inform you that you were overpaid AFDC-Foster Care
benefits
(11) for
for
__________________________________________________________
(NAME OF CHILD)
(12) the period of
to
______________________
__________________________
(MM/DD/YYYY)
(MM/DD/YYYY)
(13) Total amount you received: $
________________________________
(14) Total amount you should have received: $
___________________
(15) Total amount of Overpayment: $
____________________________
(16) Date of Discovery:
Collection is
____________________________
permitted if demand is made within one year of discovery.
(17) You are required to repay the overpayment amount of
$_________________ .
(18) Reason for the overpayment:
I
(A) Child/Youth left your foster care placement on
you were not entitled to payments for
___________________
(DATE)
him/her on or after this date; or
I
(B) Other:
If you disagree with the reason for overpayment or the amount
of the overpayment, you may request a hearing. Please see
following pages for hearing instructions.
If you agree with the reason for the over payment and the
overpayment amount, 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:
2) Sign a written repayment agreement or sign a written
voluntary grant offset. Please contact the worker at the top of
this form to discuss the terms for these options.
If you have any questions regarding the overpayment computation
or repayment arrangements, please contact the worker at the top of
Relevant Law: Welfare and Institutions Code sections 11466.23,
this form.
11466.235, Manual of Policies and Procedures (MPP) sections 22-
009, 45-304, 45-305, and 45-306.
NA 1261 (1/16) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE ___ OF ___
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