Form Na 840a - Notice Of Action - Determination Of Good Cause/no Good Cause
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1
2NOTICE 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.
The box that is checked applies to you:
_____________________________________________ ,
_____________________________________________ ,
your cash aid will not go down on ______________ , as we
your cash aid will go down on ________________, as we told
told you it would. We are not lowering your cash aid because
you it would in the Notice of Action (NA 840) sent to you on
_____________________ .
you had a good reason for not doing your Welfare to Work
assignment.
After talking to you and/or looking at information you gave us:
This will not count as an instance of noncompliance in
We decided you did not have a good reason for not doing
your case record.
your Welfare to Work assignment; and
You still must participate in Welfare to Work activities
You did not agree to sign a compliance plan as required.
unless we say you do not have to.
If you have any questions, call your Welfare to Work worker at:
You may file for a State hearing if you disagree with this decision.
(
) ______ - __________ right away.
If you have questions, call your Welfare to Work worker at:
(
) _______ - _____________ right away.
_____________________________________________ ,
your cash aid will not go down on ___________________, as
we told you it would. You did not have a good reason for not
doing your Welfare to Work assignment, but you agreed to
sign a compliance plan. If you complete the compliance plan,
this will not count as an instance of noncompliance in your
case record.
You may file for a State hearing if you disagree with our finding
that you did not have a good reason for not doing your
assignment.
If you do not do what the compliance plan says:
We will lower your cash aid unless we decide you had a
good reason for not completing the plan.
You will get a new notice if we have to lower your cash
aid.
This will count as an instance of noncompliance in your
case record.
These rules apply: CalWORKs MPP Section 42-713 (good
cause); 42-721 (good cause and noncompliance). You may review
If you have any questions, call your Welfare to Work worker at:
these rules at your welfare office.
(
) ______ - __________ right away.
NA 840A (10/03) REQUIRED FORM - SUBSTITUTE PERMITTED
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