Form Na 1211 - Notice Of Action - Denial
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2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION - DENIAL
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 you how.
Your benefits may not be changed if you ask for a
hearing before this action takes place.
INSTRUCTIONS: Use to deny Kin-GAP when there is
no eligible child in the home. In the action line, enter
the date of application.
The County has denied your application for Kin-GAP
cash aid dated____________.
Here’s why:
You are not eligible for Kin-GAP for one or more of the
following reasons:
The child you are caring for is over 18.
The child has not lived with you for at least 12
months.
A legal guardianship has not been established for
this child.
The juvenile cour t dependency has not been
dismissed.
The child’s income is over the limit.
The child’s property is over the limit. See attached
page.
If the County figured that the child’s car or other
vehicle was worth more than you think it’s
worth, you can give the County proof that it is
worth less. Ask the County how. If you can
provide it is wor th less the child may get
Kin-GAP cash aid.
Other____________________________________.
NA 1211 (2/00)
Page ____ of ____
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