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									                                               Georgia Department of Human Resources
                                                   DISPOSITION NOTIFICATION
                                            TANF LUMP SUM INELIGIBILITY
                     _______________________________ County Department of Family and Children Services
                                                                                              ____________________________________
                                                                                                      Date Mailed or Given

_________________________________________________________                                    _____________________________ _______
                                                                                                    Case Manager / Caseload

_________________________________________________________                                     ____________________________________
                                                                                                         Case Number

_________________________________________________________                                    ____________________________________
                                                                                                       Telephone Number
                  PROCEDURES FOR REQUESTING A HEARING ARE ON THE BACK OF THIS FORM
                                    FOR FREE LEGAL SERVICES CALL _________________________


        Your TANF application is denied effective ______________________.
        Your TANF cash assistance is being stopped effective ____________________.
        Your TANF cash assistance is being decreased from $________ to $________ effective ___________________.
        The TANF period of ineligibility has changed because verified information is different than the information originally
         provided.
        The TANF period of ineligibility has been shortened because of a change in circumstances.

REASON:

________________________ received a lump sum from ____________________ of $_________________ on _____________.
           Name                                                  Source                       Net Amount                 Date

This results in TANF ineligibility for ___________________________________________________________ who must live on this money
                                                       Names of Ineligible Individuals

for ________________ months, from __________________ through __________________.
     Number of Months                       Month/Year                      Month/Year

You have been overpaid for the month(s) of ________________________ in the amount of $_____________________.
                                                Month(s) of Overpayment                          Amount of Overpayment

If you need temporary assistance after the period of ineligibility for those individuals ineligible because of lump sum income, you should apply
for those individuals in __________________.
                           Month/Year

LUMP SUM BUDGET:

$________ (net lump sum income) divided by $________ (federal poverty level for _____ persons) equals ________ months of ineligibility.

If lump sum verification has not yet been received, the above information may change.

The period of ineligibility may be shortened in some cases. For example, you may need to spend the lump sum income to provide your family
shelter in an emergency or the lump sum income may become unavailable for reasons beyond your control. Contact your case manager.
Keep receipts for money you spend.

If another needy person is in your family (for example, a new baby) call your case manager. This person may be eligible for cash assistance.

If any of your family’s other benefits are affected by this lump sum income, you will receive a separate notice.

REGULATION: Section 1650. The lump sum period of ineligibility is calculated by dividing the net amount of the lump sum income by the
federal poverty level for the lump sum budget unit. The result is the number of months for which members of the lump sum budget unit are
ineligible.

Form 249LS (Rev. 05/2001)
                                                                          Today’s Date
If you want a hearing, fill out this form and return the top portion to
your county Department of Family and Children Services office
Signature of Person Requesting Hearing                                    Telephone Number Where You Can Be Reached



Use this space to tell us why you want a hearing: __________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________


CHECK () ONE

     I DO NOT WANT to continue receiving the cash assistance I now receive while waiting for the hearing decision.

     I WANT to continue receiving the cash assistance I now receive while waiting for the hearing decision. I understand that I WILL BE
      REQUIRED TO REPAY the Department of Human Resources any overpayment in TANF cash assistance to which I was not entitled
      as determined by the hearing official.

------------------------------------------------------------------------------------------------------------------
If your eligibility changes you will be advised in writing. If, for any reason, you think proper consideration has not been given to your situation,
you have the right to request a hearing with the Office of State Administrative Hearings. Procedures for requesting a hearing are below.

If you request a hearing within ten days from the date on the top front of this form, your TANF cash assistance may be continued or your case
returned to the same status it was in prior to this action, unless the hearing official decides the sole reason is one of state or federal law or
policy.


                                                          HEARING PROCEDURES

You may request a hearing either orally or in writing by notifying the county Department of Family and Children Services. You have thirty
days from the date on this form to request a hearing. If you request a hearing for TANF orally, you have fifteen days from the date of your
oral request to submit your request in writing. The hearing is held for TANF by a representative of the Office of State Administrative Hearings.
Any member of the staff will be glad to furnish the necessary forms and help you request a hearing, and assist you in every way possible to
prepare for the hearing. You may be represented at such a hearing by an authorized representative, such as legal counsel, a relative, friend
or other spokesperson, or you may represent yourself. Free legal services may be available to you in your community. If you are interested in
legal services, call the number for free legal services listed on the front of this form.




Form 249LS (Rev. 08/2001) Reverse

								
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