medi cal 9.9

							Medi-Gal Change

NOTICE ACTION OF

COUNTY OF ORANGE

STATEOF CALIFORNIA HEALTHAND HUMANSERVICES AGENCY CALIFORNIA DEPARTMENT SOCIALSERVICES OF

NoticeDate Case Name Case Number Worker Name Worker Number Telephone Worker Hours Address

09/i 4i2009 DanielKauwe 1B2B844 H. Fernandez PSGK (714) 43s-7499 SocialServicesAgcy, 7:00 AM - 5:00 PM 1928S GrandAVE SantaAna CA 92705-4902

Daniel Kauwe 933 beclonia AVE costamesa cA 92626-0000

Questions? Ask your Worker. State Hearing: lf you think this actionis wrong,you can ask for a hearing. The back of this pagetellsyou how. Your benefitsmay not be changed if you ask for a hearingbefore this actiontakes place.

This Noticeappliesto: DanielKauwe Your shareof cost has been changedto $ 821.00per month beginning 08/01 /2009. Here'swhy: You and/oryour family'snet nonexempt incomehas decreased. You and/oryour family'snet nonexempt incomehas increased. This noticeshowshow your shareof cost was determined. lf you have any questions aboutthis actionor if there are morefactsaboutyour conditions whichyou have not reported us, pleasewriteor telephone, to We will answeryour questions make an appointment or to see you. Take your plasticcardto your medicalprovider whenever you need care. Do not throw away yout" plasticlD card. MC 239 C-M Medi-Cal Noticeof Action-Change in Shareof Cost

Gross lncome Net Non-Exempt Income Maintenance Need ExcessIncome/Share-of-Cost

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204L . 3r I 42L, 3I 600. 00 821. 00

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:: Rules: Theserulesapply.You may reviewthem at your weffareoffice:Title22i 50501,50557,50601, s0653,50658
25-MCIncomeBudoet

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