Form Na 274d - Notice Of Action (Continuation Page) - Overpayment Amount Owed (For Overpayments Occurring On Or After 9/1/95 - 12/31/97)

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NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date : ____________________________________________________________________________
Case
Overpayment Amount Owed
Name
: ____________________________________________________________________________
(For Overpayments Occurring on or after 9/1/95 - 12/31/97)
Number
: ____________________________________________________________________________
Overpayment Month and Year:
______________
______________
______________
______________
______________
A
Family Gross Income
____________________________
$
______________
______________
______________
______________
______________
____________________________
+
______________
______________
______________
______________
______________
Total Gross Income 1
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Basic Need for _____ Persons
$
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Total Needs
=
______________
______________
______________
______________
______________
X
1.85
______________
______________
______________
______________
______________
185% of Needs 2
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
If 1 is larger than 2 , you were not eligible in that month and all the cash aid you got is an
overpayment. The amount of your overpayment is figured below.
B
Net Countable Income
Total Earned Income
$
______________
______________
______________
______________
______________
Work Expense Disregard
–
______________
______________
______________
______________
______________
$30 and 1/3 Disregard (Assistance Unit only)
–
______________
______________
______________
______________
______________
Subtotal
=
______________
______________
______________
______________
______________
Dependent Care Disregard
(Assistance Unit only)
–
______________
______________
______________
______________
______________
Other Countable Income (List Sources)
_______________________________
+
______________
______________
______________
______________
______________
_______________________________
+
______________
______________
______________
______________
______________
Court Ordered Child/Spousal Support Paid
for Persons Not Living in the Home
–
______________
______________
______________
______________
______________
Support Paid to Other(s) Not Living in the
Home Claimed as Federal Tax D ependent
(Non-Assistance Unit Only)
–
______________
______________
______________
______________
______________
Net Countable Income
=
______________
______________
______________
______________
______________
C Correct Cash Aid Payment
Basic Need Amount (# persons) $ Amount
(
)
(
)
(
)
(
)
(
)
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Net Countable Income
–
______________
______________
______________
______________
______________
Subtotal A
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Maximum Aid Payment (MAP)
$
______________
______________
______________
______________
______________
Special Needs
+
______________
______________
______________
______________
______________
Subtotal B
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Other State’s MAP ________________
$
______________
______________
______________
______________
______________
Special Needs (California)
+
______________
______________
______________
______________
______________
Subtotal C
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Correct Cash Aid Amount
(Lesser of Subtotal A, B or C)
$
______________
______________
______________
______________
______________
D Overpayment
Cash Aid Paid to You
$
______________
______________
______________
______________
______________
Correct Cash Aid Amount
–
______________
______________
______________
______________
______________
Subtotal D
=
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Cash Aid Paid to You
$
______________
______________
______________
______________
______________
Support Payments Collected for You
– _______________
_______________
_______________
_______________
______________
(Except for a Child Covered by Maximum
Family Grant)
Subtotal E
= _______________
_______________
_______________
_______________
______________
_______________
_______________
_______________
_______________
______________
Amount of Overpayment for Each Month
=
______________
______________
______________
______________
______________
(Lesser of Subtotal D or E)
TOTAL OVERPAYMENT (All Months)
$ ______________
Rules: These rules apply; you may review them at your
Welfare Office: MPP 44-352.12
State Hearing: If you think this action is wrong, you can ask for
a hearing. The back of Page 1 tells how.
Page____ of ____
NA 274 D (1/00) CONTINUATION PAGE - OVERPAYMENT COMPUTATIONS (ORTEGA 9/1/95-12/31/97)

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