Form Na 823 - Notice Of Action - Ancillary Expenses Approval/denial
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1
2STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF ACTION
COUNTY OF
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 you how.
As of _______________, the County has approved your request
As of _______________, the County has denied your request for
for payment of the following items needed for your approved
payment of the following items for your
Welfare to Work
Cal-Learn activity or to get a job:
Welfare to Work
Cal-Learn activity or to get a job:
Item
Cost
____________________
____________________
____________________________________ $ __________
____________________
____________________
____________________________________
__________
____________________
____________________
____________________________________
__________
____________________________________
__________
Here’s why:
____________________________________
__________
You are not in an approved
Welfare to Work
____________________________________
__________
Cal-Learn activity.
Total
$ __________
The County may continue to pay for work expenses for up to the
The cost is not necessary because: ______________________
first 12 months after you have left aid if you have a job. We will
__________________________________________________
pay only if you need it to keep your job and you cannot get the
work expenses paid from somewhere else.
You do not need these items for your
Welfare to Work
Cal-Learn activity or to get a job because: _________________
Your payments will be:
Advanced to you
Paid back to you
__________________________________________________
Paid to the store
Paid to the school
Other:
Other:
The following items you asked for were not approved for
payment:
Item
Item
You can call your Welfare to Work/Cal-Learn worker if you think this
notice is wrong.
____________________
____________________
____________________
____________________
Here’s why:
The cost is not necessary because: ______________________
__________________________________________________
You do not need ____________________ for your
Welfare to
Work
Cal-Learn activity or to get a job because:_________
__________________________________________________
Rules: These rules apply. You may review them at your welfare
Rules: These rules apply. You may review them at your welfare
office: CalWORKs Implementation Guidelines, Sections VII &
office: CalWORKs Implementation Guidelines, Sections VII &
XII, Welf. & Inst. Code 11323.2, 11323.4, 11322.9
XII, Welf. & Inst. Code 11323.2, 11323.4, 11322.9
NA 823 (8/00) REQUIRED – SUBSTITUTE PERMITTED
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