Form NA1239 SAR "Notice of Action - Continuation Page - Semi-annual Reporting Budget" - California

What Is Form NA1239 SAR?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NA1239 SAR by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form NA1239 SAR "Notice of Action - Continuation Page - Semi-annual Reporting Budget" - California

Download PDF

Fill PDF online

Rate (4.5 / 5) 46 votes
Page background image
State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION
COUNTY OF
Notice Date
: _________________________
Continued
Case Name
: _________________________
Case Number
: _________________________
Worker Name
: _________________________
Worker Number
: _________________________
Telephone Number : _________________________
Address
: _________________________
(ADDRESSEE)
_________________________
_________________________
Questions? Ask your Worker.
State Hearing: If you think this action
is wrong, you can ask for a hearing.
Page 3 tells you how. Your benefits
may not be changed if you ask for a
hearing before this action takes place.
Here’s your information:
When you get paid every week or every other
__________ Income Reported
week, here is how we figure your monthly
income:
$__________
First, we add all the income you got in the
$__________
month and divide by the total number of
payments you got. Then, we multiply that
$__________
amount by the average number of payments in
a month.
$__________
If you get paid every week, you may get
+ $__________
paid 4 or 5 times in a month. 4.33 is the
Total reported
= $__________
average number of payments in a month.
# of Payments Reported ÷__________
If you get paid every other week, you may
get paid 2 or 3 times in a month. 2.167
Weekly Amount
= $__________
is the average number of payments in a
Multiplied by
x__________
month.
Monthly Amount
= $__________
NA 1239 SAR (12/20) Continuation Page - Semi-Annual Reporting Budget
Page 1 of 4
Required Form - No Substitute Permitted
State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION
COUNTY OF
Notice Date
: _________________________
Continued
Case Name
: _________________________
Case Number
: _________________________
Worker Name
: _________________________
Worker Number
: _________________________
Telephone Number : _________________________
Address
: _________________________
(ADDRESSEE)
_________________________
_________________________
Questions? Ask your Worker.
State Hearing: If you think this action
is wrong, you can ask for a hearing.
Page 3 tells you how. Your benefits
may not be changed if you ask for a
hearing before this action takes place.
Here’s your information:
When you get paid every week or every other
__________ Income Reported
week, here is how we figure your monthly
income:
$__________
First, we add all the income you got in the
$__________
month and divide by the total number of
payments you got. Then, we multiply that
$__________
amount by the average number of payments in
a month.
$__________
If you get paid every week, you may get
+ $__________
paid 4 or 5 times in a month. 4.33 is the
Total reported
= $__________
average number of payments in a month.
# of Payments Reported ÷__________
If you get paid every other week, you may
get paid 2 or 3 times in a month. 2.167
Weekly Amount
= $__________
is the average number of payments in a
Multiplied by
x__________
month.
Monthly Amount
= $__________
NA 1239 SAR (12/20) Continuation Page - Semi-Annual Reporting Budget
Page 1 of 4
Required Form - No Substitute Permitted
State of California – Health and Human Services Agency
California Department of Social Services
Monthly Cash Aid Amount
Section A. Countable Income,
Section B. Your Cash Aid,
Month of
Month of
____________________
____________________
1. Total Self-Employment Income $
1. Maximum Aid ______ Persons
___________
(Assistance Unit +
2. Self-Employment Expenses:
Non-Assistance Unit Members) $
___________
a. 40% Standard
-
___________
OR
2. Special Needs (Assistance
Unit + Non-Assistance
b. Actual
-
___________
Unit Members)
+
___________
3. Net Earnings from
3. Net Countable Income from
Self-Employment
=
___________
Section A
-
___________
4. Total Disability-Based
4. Subtotal (if negative, enter 0)
=
Unearned Income (DBI)
___________
(Assistance Unit +
5. Maximum Aid ______ Persons
Non-Assistance Unit Members) $
___________
(Assistance Unit only)
(Excluding Penalized Persons) $
5. $550 DBI Disregard (if #4 is
___________
greater than $550)
-
___________
6. Special Needs (Assistance
Unit only)
+
6. Nonexempt Unearned
___________
Disability-Based Income
=
___________
7. Maximum Aid Subtotal
=
___________
OR
8. Full Month Aid Subtotal
7. Unused DBI Disregard
=
___________
(Lowest Amount on Line 4 or 7) =
___________
8. Net Earnings from
9. Line 8 Prorated for Part
Self-Employment (from above) +
___________
of Month
=
___________
9. Total Other Earned Income
+
___________
10. Adjustments:
10. Unused Amount of $550
25% Child Support Penalty(ies) -
___________
(from #7)
-
Other Penalties
-
___________
___________
Overpayment
-
___________
11. Subtotal
=
___________
Cal-Learn Penalties
-
___________
12. Earned Income Disregard 50% -
School Bonus ($100 or $500)
+
___________
___________
13. Subtotal
=
11. Monthly Cash Aid Amount
___________
(Line 8 or 9 Adjusted)
$
14. Nonexempt Unearned
___________
Disability-Based Income
12. Current Cash Aid Amount (If
(from #6)
+
This Amount Is More Than #11,
___________
Your Cash Aid Will Not Change) =
___________
15. Subtotal
=
___________
16. Other Nonexempt Income
(Assistance Unit +
Non-Assistance Unit Members) +
___________
Net Countable Income
=
___________
NA 1239 SAR (12/20) Continuation Page - Semi-Annual Reporting Budget
Page 2 of 4
Required Form - No Substitute Permitted
If the amount of supportive services the
YOUR HEARING RIGHTS
county pays while you wait for a hearing
You have the right to ask for a hearing if
decision is not enough to allow you to
you disagree with any county action. You
participate, you can stop going to the activity.
have only 90 days to ask for a hearing.
Cal-Learn:
The 90 days started the day after the
county gave or mailed you this notice. If
You cannot participate in the Cal-Learn
you have good cause as to why you were
Program if we told you we cannot serve you.
not able to file for a hearing within the 90
We will only pay for Cal-Learn supportive
days, you may still file for a hearing. If
you provide good cause, a hearing may
services for an approved activity.
still be scheduled.
OTHER INFORMATION
Medi-Cal Managed Care Plan Members:
If you ask for a hearing before an action on
The action on this notice may stop you from
Cash Aid, Medi-Cal, CalFresh, or Child Care
getting services from your managed care health
takes place:
plan. You may wish to contact your health plan
Your Cash Aid or Medi-Cal will stay the same
membership services if you have questions.
while you wait for a hearing.
Child and/or Medical Support: The local child
Your Child Care Services may stay the same
support agency will help collect support at no
while you wait for a hearing.
cost even if you are not on cash aid. If they now
collect support for you, they will keep doing so
Your CalFresh benefits will stay the
unless you tell them in writing to stop. They will
same until the hearing or the end of your
send you current support money collected but
certification period, whichever is earlier.
will keep past due money collected that is owed
If the hearing decision says we are right, you
to the county.
will owe us for any extra Cash Aid, CalFresh
Family Planning: Your welfare office will give
or Child Care Services you got. To let us
you information when you ask for it.
lower or stop your benefits before the hearing,
Hearing File: If you ask for a hearing, the State
check below:
Hearing Division will set up a file. You have the
Yes, lower or stop: n Cash Aid n CalFresh
right to see this file before your hearing and to
n Child Care
get a copy of the county’s written position on
your case at least two days before the hearing.
While You Wait for a Hearing Decision for:
The state may give your hearing file to the
Welfare to Work:
Welfare Department and the U.S. Departments
of Health and Human Services and Agriculture.
You do not have to take part in the activities.
(W&I Code Sections 10850 and 10950.)
You may receive child care payments for
employment and for activities approved by the
county before this notice.
If we told you your other supportive services
payments will stop, you will not get any more
payments, even if you go to your activity.
If we told you we will pay your other supportive
services, they will be paid in the amount and in
the way we told you in this notice.
To get those supportive services, you must
go to the activity the county told you to
attend.
NA BACK 9 (Replaces NA BACK 8 And EP 5) (Revised 2/19)
Page 3 of 4
Required Form - No Substitute Permitted
TO ASK FOR A HEARING:
Fill out this page.
Make a copy of the front and back of this page for your records. If you ask, your worker will get
you a copy of this page.
Send or take this page to:
OR
Call toll free: 1-800-952-5253 or for hearing or speech impaired who use TDD, 1-800-952-8349.
To Get Help: You can ask about your hearing rights or for a legal aid referral at the toll-free
state phone numbers listed above. You may get free legal help at your local legal aid or welfare
rights office.
If you do not want to go to the hearing alone, you can bring a friend or someone with you.
HEARING REQUEST
I want a hearing due to an action by the Welfare Department of
County
_____________________________________
about my: n Cash Aid n CalFresh
n Medi-Cal n Other (list)
______________________________________
Here’s Why:
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
n If you need more space, check here and add a page.
n I need the state to provide me with an interpreter at no cost to me. (A relative or friend cannot
interpret for you at the hearing.)
My language or dialect is:
__________________________________________
Name of Person Whose Benefits Were Denied,Changed or Stopped
Date of Birth Phone Number
Street Address
City
State
Zip Code
Signature
Date
Name of Person Completing This Form
Phone Number
n I want the person named below to represent me at this hearing. I give my permission for
this person to see my records or go to the hearing for me. (This person can be a friend or
relative but cannot interpret for you.)
Name
Phone Number
Street Address
City
State
Zip Code
NA BACK 9 (Replaces NA BACK 8 And EP 5) (Revised 2/19)
Page 4 of 4
Required Form - No Substitute Permitted
Page of 4