Form Na 833 - Notice Of Action - Child Care Change
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1
2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHILD CARE CHANGE
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. Your benefits may not be
changed if you ask for a hearing before this action
takes place. If you and the county disagree or if
you have not heard back from your worker, do not
wait to ask for a hearing. You must ask for the
hearing before a certain number of days. See the
back of this notice for more information and to find
out how to ask for a hearing.
As of ___________________________________ the child care for
You must tell us before you change child care providers except
DATE
in an emergency or we may not be able to reimburse the new
____________________________ is changed for the following
provider.
NAME OF CHILD
reason:
The county has changed the reimbursement rate from
$__________ per ________ to $__________ per _________.
Child(ren): ____________________________________________
The county has changed your reimbursement method for
$ _______ rate
Cal-Learn
CalWORKs child care from __________ to
_______________, because _________________________.
X
________ hours
days
weeks
month
Your child care provider has changed. Your
Cal-Learn
=
$ _______ per _____________
CalWORKs child care at __________ has been paid until
Provider name: ________________________________________
____________. Reimbursement for _____________________
starts after that date.
Child(ren): ____________________________________________
HERE’S WHY:
$ _______ rate
Your child care rate changed
X
________ hours
days
weeks
month
Your child care provider changed.
Your child’s age has changed.
=
$ _______ per _____________
Your child care hours changed.
Provider name: ________________________________________
The State of California changed reimbursement limits.
You asked for this change.
Other:
Child(ren): ____________________________________________
Your new child care reimbursement is figured on this notice.
$ _______ rate
X
________ hours
days
weeks
month
The county will only reimburse child care for the hours and days
you go to your approved activity/program. The county will only
=
$ _______ per _____________
reimburse for child care to providers who are registered with
TrustLine, or are exempt from TrustLine-registration.
Provider name: ________________________________________
If you have selected a new provider who is required to register with
TrustLine, this provider is not eligible for reimbursement until
registered with TrustLine. License-exempt child care providers who
Child care for children not listed here stays the same.
are required to be TrustLine-registered can get retroactive-
reimbursement for up to 120 calendar days from the date child
The rates listed above are what your child care provider charges or
care services were requested and provided, if the provider later
the most we can reimburse based on your area’s child care costs,
becomes TrustLine-registered.
whichever is less. You are responsible to pay any difference above
Rules: These rules apply. You may review them at your welfare
this rate.
office: CalWORKs MPP Sections 47-260, 47-430.2, 47-620.32;
Welfare and Institutions Code Sections 11322.9, 11323.6,
11323.4, 11323.8. Education Code Sections 8350-8353, 8357, or
visit or
NA 833 (10/14) REQUIRED FORM - SUBSTITUTES PERMITTED
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