VI. Immunization Good Cause Request Form : PDF (CDSS) English: Spanish : CW 42: CW: Statement of Facts - Homeless Assistance : PDF (CDSS) English: Spanish : CW 61: CW, WTW: Health Care Provider - Authorization to Release Medical Information : PDF (CDSS) English: Spanish : CW 8: CW: Statement of Facts for an Additional Person : PDF (CDSS) English : Spanish: CW 8 A: CW: Statement of Facts to Add … PUB 389 (8/17) - California Electronic Benefit Transfer (EBT) Card - How To Use Your EBT Card To Make A Purchase. Download Fillable Form Soc2298 In Pdf - The Latest Version Applicable For 2021. a. CDS. See authoritative translations of Cds in English with example sentences and audio pronunciations. CDSS forms and publications are available only in Portable Document Format (PDF). Included in the paperwork will be a Kaiser Permanente Authorization for Use and Disclosure Form (if the applicant is a Kaiser patient) and the required Health Care Certification Form (SOC 873) that will need to be returned completed by a licensed health care professional. Problems with downloading forms? Download Fillable Form Soc2298 In Pdf - The Latest Version Applicable For 2021. Many translated example sentences containing "cdss" – Spanish-English dictionary and search engine for Spanish translations. Fill out, securely sign, print or email your LIC 9182 (11/15) - Criminal Background Clearance Transfer ... - CDSS - cdss ca instantly with SignNow. Available for PC, iOS and Android. Singing and Playing Music in REAL TIME! For more information on how to fill out forms, please visit the section " How to fill out forms ". AB 490 Summary McKinney-Vento Homeless Education Act Fostering Connections to Success Act (Federal) Foster Care. LANGUAGE SERVICES LIST OF TRANSLATED CDSS FORMS AND MESSAGES If you have access to the Internet you can visit our website at www dss cahwnet gov cdssweb FormsandPu Claim Your 2019 State And Federal Credits - You Earned It - It's Your Money, PUB 438 (11/15) - TrustLine Parent Pamphlet, PUB 439 (11/15) - License Exempt Provider Pamphlet, PUB 456 (3/11) - Important Information For Relatives Pamphlet, PUB 463 (10/13) - Education Travel Reimbursement, PUB 468 (10/16) - Approved Relative Caregivers Funding Option Program, PUB 470 (7/17) - Your Rights Under Adult Protective Services, PUB 470L (1/19) - Your Rights Under Adult Protective Services, PUB 474 (12/14) - Rights of Resident Councils, PUB 475 (10/18) - Residential Care Facility for the Elderly (RCFE) Complaint Poster, PUB 484 (7/15) - Keep More Of Your Money - Poster, PUB 486 (7/15) - Understanding The EBT Client Website, PUB 488 (2/16) - Foster Youth Mental Health Bill of Rights - Questions to Ask About Medications, PUB 490 (4/18) - Know Your Sexual and Reproductive Health Rights, PUB 500 (2/16) - Complaint Investigation Process - Statewide Children's Residential Program - State Licensed Foster Parents, PUB 501 (2/16) - Complaint Investigation Process - Statewide Children's Residential Program -County Licensed Foster Parents, PUB 502 (2/16) - Complaint Investigation Process - Statewide Children's Residential Program - Foster Family Agency Certified Parents, PUB 511 (4/19) - Finding A Competent Therapist, PUB 515 (10/19) - Risks and Effects of Lead Poisoning, PUB 516 (9/19) - You May Be Eligible For 12 Months Of Child Care, QR 377.1 (4/04) - Food Stamp Notice Of Approval, QR 377.2 (10/11) - CalFresh Notice Of Expiration Of Certification, QR 377.4 (1/04) - Food Stamp Notice Of Change For Quarterly Reporting Household, QR 377.5 (2/04) - Food Stamp Mid-Quarter Status Report, QR 2103 (11/11) - Reminder For Teens Turning 18 Years Old, RCA 43 (5/03) - Refugee Cash Assistance (RCA) Notice Of A Participation Problem, RCA 44 (5/03) - Refugee Cash Assistance (RCA) Notice Of No Good Cause Determination And Compliance Plan Appointment, RFA 00 (8/17) - Conversion to Resource Family: Release of Information, RFA 00A (2/17) - Conversion - Resource Family Application, RFA 01A (7/19) - Resource Family Application, RFA 01B (7/19) - Resource Family Criminal Record Statement, RFA 03 (7/19) - Resource Family Home Health And Safety Assessment Checklist, RFA 05 (5/18) - Resource Family Approval - Written Report, RFA 07 (2/18) - Resource Family Approval (RFA) Health Screening, RFA 09 (1/18) - Notice Of Action Regarding Resource Family Approval, RFA 09B (1/18) - Notice Of Action To Individual Regarding Resource Family Approval Criminal Record Exemption Decision, RFA 09E (9/17) - Order To Individual of Exclusion From Resource Family Homes And Department Licensed Facilities, RFA 09I (9/17) - Order To Individual Of Immediate Exclusion From Resource Family Homes And Department Licensed Facilities, RFA 10 (12/19) – Resource Family Approval Portability Application, RFA 11 (12/19) – Resource Family Approval Statement Acknowledging Requirement To Report Child Abuse, RFA 100 (9/18) - Notice Of Action - Issuance Interim Funding For Emergency Caregivers, RFA 100A (9/18) - Notice Of Action - Discontinue Interim Funding For Emergency Caregivers, RFA 105 (11/19) – Notice of Action – Issuance Emergency Caregiver Funding, RFA 105A (11/19) – Notice of Action – Discontinue Emergency Caregiver Funding, RFA 809 (9/17) - Resource Family Visit Record, RFA 809C (9/17) - Resource Family Visit – Corrective Action Plan, RFA 812 (6/17) - Detail Supportive Information, RFA 9099C (9/17) - Complaint Investigation Report - Continued, RS 3 (5/03) - Service Provider Referral/Notification Form, RS 36 (3/08) - Employment And Training Requirements For Refugee Cash Assistance (RCA), SAR 2 (6/19) - Reporting Changes For Cash Aid And CalFresh, SAR 2LP (6/19) - Reporting Changes For Cash Aid and CalFresh, SAR 3 (2/15) - Mid-Period Status Report For Cash Aid and CalFresh, SAR 7 (12/14) - SAR 7 Eligibility Status Report, SAR 7 Addendum (4/13) - Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFresh, SAR 7A (12/14) - How To Fill Out Your SAR 7 Eligibility Status Report, SAR 22 (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid and/or CalFresh, SAR 23 (3/13) - Senior Parent Statement Of Facts, SAR 72 (3/13) - Sponsor's Semi-Annual Income And Resources Report, SAR 73 (3/13) - Senior Parent Semi-Annual Income Report, SAWS 1 (8/13) - Initial Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs, SAWS 2 PLUS (4/15) - Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs, SAWS 2A SAR (4/15) - Rights and Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, And/Or Medi-Cal/34-County Medical Services Program (CMSP), SAWS 30 (3/19) - Notification Of New Employment, SDFAP 01 (12/19) - State Disaster Food Assistance Program (SDFAP) Certification Of Eligibility, SDFAP 02 (12/19) - State Disaster Food Assistance Program (SDFAP) Tracking Report, SNB 1 (8/18) - Notice To CalFresh Recipients Supplemental Nutrition Benefit (SNB) Program, SNB 2 (8/18) - Notice Of Approval For Supplemental Nutrition Benefit (SNB) Program, SNB 3 (8/18) - Notice Of Change For Supplemental Nutrition Benefit (SNB) Program, SNB 4 (8/18) - Notice Of Expiration Of Certification For Supplemental Nutrition Benefit (SNB) Program, SNB 5 (8/18) - Notice Of Discontinuance For Supplemental Nutrition Benefit (SNB) Program, SNB 7 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Receiving Intercounty Transfer, SNB 8 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Sending Intercounty Transfer, SOC 152 (1/12) - Placement Agency - THP Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In THP Plus Foster Care Provider, SOC 153 (1/12) - Placement Agency - Foster Family Agency Agreement, SOC 154B (1/12) - Agency - Group Home Agreement Nonminor Dependent Placed By Agency In Group Home, SOC 155 (5/99) - Voluntary Placement Agreement - Placement Request, SOC 156 (12/11) - Agency - Foster Parents Agreement - Child Placed by Agency in Foster Home, SOC 156A (1/12) - Agency - Foster Parents Placement Agreement Nonminor Dependent Placed By Agency In Foster Home, SOC 161 (9/11) - Six-Month Certification Of Extended Foster Care Participation, SOC 162 (7/18) - Mutual Agreement for Extended Foster Care, SOC 163 (7/18) - Voluntary Re-Entry Agreement For Extended Foster Care, SOC 295 (9/18) - Application For In-Home Supportive Services, SOC 295L (9/18) – Application For In-Home Supportive Services, SOC 310 (1/03) - Statement Of Facts For In-Home Supportive Services, SOC 332 (9/09) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist), SOC 332L (1/19) - In-Home Supportive Services (Recipient/Employer Respon, SOC 341 (11/18) - Report Of Suspected Dependent Adult/Elder Abuse, SOC 341A (3/15) - Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders, SOC 369 (12/10) - Agency-Relative Guardianship Disclosure, SOC 369A (7/15) - Kinship Guardianship Assistance Payment (KIN-GAP) Program Agreement Amendment, SOC 404 (10/11) - In-Home Supportive Services Program Direct Deposit Enrollment/Change/Cancellation Form, SOC 409 (7/03) - IHSS/CMIPS Elective State Disability Insurance (SDI) Form, SOC 426 (6/16) - In-Home Supportive Services (IHSS) Program Provider Enrollment Form, SOC 426A (1/16) - In-Home Supportive Services (IHSS) Program Recipient Designation Of Provider, SOC 426C (10/10) - In-Home Supportive Services (IHSS) Program California Code Sections, SOC 445 (6/99) - Medi-Cal Recovery For The Personal Care Services Program, SOC 450 (4/99) - Voluntary Services Certification, SOC 453 (1/18) - Cash Assistance Program For Immigrants (CAPI) Statement Of Household Expenses And Contributions, SOC 455 (1/99) - Authorization for State Reimbursement of Interim Assistance, SOC 500 (4/18) - Level Of Care (LOC) Digital Scoring Form, SOC 501 (12/17) - Levels Of Care (LOC) Rate Determination Matrix, SOC 804 (2/20) - Statement Of Facts For Determining Continuing Eligibility For The Cash Assistance Program For Immigrants (CAPI), SOC 807 (7/00) - Cash Assistance Program For Immigrants (CAPI) Request For Waiver Of Overpayment Recovery - Income/Expenses, SOC 807A (7/00) - Cash Assistance Program For Immigrants (CAPI) Request For Waiver Of Overpayment Recovery - Without Fault, SOC 809 (10/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Statement, SOC 814 (5/19) - Statement Of Facts Cash Assistance Program For Immigrants (CAPI), SOC 818 (12/10) - Relative Or Non-Relative Extended Family Member Caregiver Assessment, SOC 825 (6/06) - Protective Supervision 24-Hours-A-Day Coverage, SOC 827 (12/06) - IHSS Program Individual Emergency Back-Up Plan, SOC 829 (10/18) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider Direct Deposit Enrollment/Change/Cancellation Form, SOC 830 (1/08) - Request for Conditional CAPI After Naturlization Pending SSI/SSP Eligiblity Determination, SOC 832 (1/13) - Notice of Child Abuse Central Index Listing, SOC 834 (3/13) - Request for Grievance Hearing, SOC 838 (10/12) - In-Home Supportive Services (IHSS) Recipient Request For Assignment Of Authorized Hours To Providers, SOC 839 (6/18) - In-Home Supportive Services (IHSS) Recipient Time Sheet Signature Authorization, SOC 839A (5/18) - In-Home Supportive Services (IHSS) Cancellation Of Authorized Representative, SOC 840 (10/12) - In-Home Supportive Services (IHSS) Program Provider Or Recipient Change Of Address And/Or Telephone, SOC 846 (10/19) - In-Home Supportive Services (IHSS) Program Provider Enrollment Agreement, SOC 847 (5/16) - Important Information For Prospective Providers About The In-Home Supportive Services (IHSS) Program Provider Enrollment Process, SOC 848 (2/20) - In-Home Supportive Services Program Notice Of Provider Eligibility, SOC 848A (5/16) - In-Home Supportive Services Program Lapse of Ten-Year Timeframe for Tier 2 Crime, SOC 849 (10/09) - In-Home Supportive Services Program Notice Of Incomplete Provider Enrollment Form, SOC 850 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility, SOC 851 (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Provider Ineligibility Incomplete Provider Process, SOC 851A (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Incomplete Provider Process 15-Day Notification, SOC 852 (1/11) - In-Home Supportive Services Program Notice Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Of Supportive Services Program), SOC 852A (5/16) - IHSS Program Notice To Provider Applicant Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 853 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility, SOC 854 (1/11) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility, SOC 854L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility, SOC 855 (5/16) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process, SOC 855L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process, SOC 855A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program), SOC 855AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program), SOC 855B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 855BL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies), SOC 856 (1/12) - To Request Appeal Of Provider Enrollment Denial, SOC 856L (1/19) - To Request Appeal Of Provider Enrollment Denial, SOC 857 (5/16) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver, SOC 857L (10/18) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver, SOC 857A (4/12) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver, SOC 857AL (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver, SOC 857B (6/16) - In-Home Supportive Services Program Notice To Provider Of Provider Ineligibility Criminal Background Check Needed, SOC 858 (12/11) - In-Home Supportive Services Provider Notification, SOC 858A (1/11) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 858B (5/16) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 859A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 859AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction, SOC 859B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 859BL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction, SOC 860 (7/18) - Sponsor's Statement Of Facts Income And Resources, SOC 861 (10/10) - Safely Surrendered Baby Medical Questionnaire, SOC 862 (5/16) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver, SOC 862L (10/18) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver, SOC 863 (5/19) - In-Home Supportive Services (IHSS) Applicant Provider Request For General Exception, SOC 864 (3/11) - In-Home Supportive Services (IHSS) Program Individualized Back-up Plan and Risk Assessment, SOC 865 (7/12) - IHSS Request For Applicant Provider Reference, - IHSS Request For Applicant Provider Reference, SOC 870 (5/16) - In-Home Supportive Services Program (IHSS) Notice To Provider Of Provider Eligibility Acknowledgment Of Receipt Of Waiver, SOC 873 (10/16) - In-Home Supportive Services (IHSS) Program Health Care Certification Form, SOC 873L (1/19) - In-Home Supportive Services (IHSS) Program Health Care Certification Form, SOC 874 (10/16) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement, SOC 874L (1/19) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement, SOC 875 (11/11) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement, SOC 875L (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement, SOC 876 (5/17) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted, SOC 876L (10/18) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted, SOC 881 (6/12) - In-Home Supportive Services Program Notice To Provider Of Inactivity, SOC 885 (6/13) - In-Home Supportive Services (IHSS) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change, SOC 2255 (3/19) - In-Home Supportive Services (IHSS) Program Provider Workweek & Travel Time Agreement, SOC 2256 (11/15) - In-Home Support Services Program Recipient And Provider Workweek Agreement, SOC 2257 (12/17) - In-Home Supportive Services Program Notice To Provider Of First/Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2257A (12/17) - In-Home Supportive Services Program Notice To Recipient Of Provider’s First/Second Violation For Exceeding Workweek And/Or Travel Time Limits/, SOC 2257B (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation No Record Of Completion Of Review Of Instructional Materials, SOC 2257C (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2258 (3/16) - In-Home Supportive Services Program Notice To Provider Of Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2258A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2259 (3/16) - In-Home Supportive Services Program Notice To Provider Of Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2259A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2263 (3/16) In-Home Supportive Services Program Notice To Provider Rescinding Violation, SOC 2264 (3/16) In-Home Supportive Services Program Notice To Recipient Rescinding Provider Violation, SOC 2265 (3/16) - In-Home Supportive Services Program Notice To Provider Reduction Of Total Violation Count, SOC 2266 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval Of Exception To Exceed Weekly Hours, SOC 2266A (1/16) - In-Home Supportive Services Program Notice To Provider Approval Of Exception To Exceed Weekly Hours, SOC 2267 (1/16) - In-Home Supportive Services Program Notice To Recipient Denial Of Exception To Exceed Weekly Hours, SOC 2267A (1/16) - In-Home Supportive Services Program Notice To Provider Denial Of Exception To Exceed Weekly Hours, SOC 2268 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval For Provider To Work Alternate Schedule Due To Recurring Event, SOC 2268A (1/16) - In-Home Supportive Services Program Notice To Provider Approval To Work Alternate Schedule Due To Recurring Event, SOC 2269 (1/16) In-Home Supportive Services Program Notice To Recipient Cancellation Of Alternate Schedule Due To Recurring Event, SOC 2269A (1/16) In-Home Supportive Services Program Notice To Provider Cancellation Of Alternate Schedule Due To Recurring Event, SOC 2270 (2/16) - In-Home Supportive Services Program Notice To Recipient Failure To Complete Workweek Agreement (SOC 2256), SOC 2270A (1/16) In-Home Supportive Services Program Notice To Provider Failure To Complete Workweek And Travel Agreement (SOC 2255), SOC 2271 (11/15) - In-Home Supportive Services (IHSS) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours, SOC 2272 (7/16) In-Home Supportive Services Program Notice To Provider Of Right To Dispute Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2272A (4/16) - In-Home Supportive Services Program Notice To Provider Acknowledgement Of Receipt Of County Violation Review, SOC 2272B (4/16) - In-Home Supportive Services Program Notice To Recipient Acknowledgement Of Provider's Request For County Violation Review For Exceeding Workweek And/or Travel Time Limits, SOC 2273 (11/18) In-Home Supportive Services Program State Administrative Review Request Of Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2279 (1/16) - In-Home Supportive Services (IHSS) Program Live-In Family Care Provider Overtime Exemption, SOC 2271A (11/15) - In-Home Supportive Services (IHSS) Program Recipient Notice Of Maximum Weekly Hours, SOC 2280 (6/16) In-Home Supportive Services Program Notice To Provider Upholding First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2281 (6/16) In-Home Supportive Services Program Notice To Recipient Upholding Provider’s First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2282 (9/18) In-Home Supportive Services Program Notice To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2283 (9/18) In-Home Supportive Services Program Notice To Recipient Upholding Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2286 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2287 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits, SOC 2288 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Rescinding Third Violation Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2289 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Rescinding Provider’s Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits, SOC 2290 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Fourth Violation (One-Year Period Of Ineligibility), SOC 2291 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Fourth Violation (One-Year Period Of Ineligibility), SOC 2292 (1/19) - In-Home Supportive Services Program Notice To Provider Of Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272), SOC 2293 (1/19) - In-Home Supportive Services Program Notice To Recipient Of Provider's Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272), SOC 2298 (1/19) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Form For Federal And State Tax Wage Exclusion, SOC 2299 (1/19) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Cancellation Form For Federal And State Tax Wage Exclusion, SOC 2300 (2/17) - In-HomeSupportive Services Program Notice To Applicant Of Application ConfirmationNumber, SOC 2301 (4/17) - In-Home Supportive Services (IHSS) Or Waiver Personal Care Services (WPCS) Recipient Confirmation Of Enrollment In Electronic, SOC 2302 (5/19) - In-Home Supportive Services (IHSS) Program Provider Paid Sick Leave Request Form, SOC 2303 (12/19) - In-Home Supportive Services Program Notice To Provider Of Incomplete Paid Sick Leave Request Form (SOC 2302), SOC 2305 (8/19) - In-Home Supportive Services (IHSS) Program Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), SOC 2306 (1/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Referral Justification, SOC 2307 (1/18) - In-Home Supportive Services (IHSS) Program Extraordinary Circumstances Secondary Evaluation Worksheet, SOC 2308 (2/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Approved Exemption Provider Agreement, SOC 2309 (2/18) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2309A (2/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2310 (5/19) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Ineligibility For Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2310A (5/19) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Ineligibility For Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances, SOC 2311 (2/18) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (SOC 2308), SOC 2312 (3/20) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Change In Extraordinary Circumstances Exemption Eligibility, SOC 2312A (3/20) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Change In Extraordinary Circumstances Exemption Eligibility, SOC 2313 (3/20) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) State Administrative Review Request Form, SOC 2323 (12/18) - In-Home Supportive Services Program - Provider Requirements For Minor Recipients Living With Their Parents, SOC 2325 (9/19) - In-Home Supportive Services Program Notice To Provider Of Non-Acceptance Of Subsequent Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2), SOC 2326 (10/19) - In-Home Supportive Services (IHSS) Recipient’s Responsibility To Stop Sexual Harassment In The Workplace, SOC 2327 (10/19) - In-Home Supportive Services (IHSS) Provider’s Right To File A Sexual Harassment Complaint, SSGP 45 (3/12) - The State Supplemental Grant Program (SSGP), SSP 14 (9/10) - Authorization For Reimbursement Of Interim Assistance Initial Claim or Posteligibility Case, SSP 17 (4/99) - Notice Of Action Right To Request A State Hearing On Interim Assistance, SSP 18 (4/15) - Notice Of Action And Right To Request A State Hearing On Interim Assistance, TEMP 2120 (8/00) - Welfare To Work Referral, TEMP 2146 (7/99) - Welfare To Work Notice and GAIN Contract Amendment, TEMP 2147 (7/99) - New GAIN Cause Determination/Compliance and CAL-Learn Requirements - GAIN Contract Amendment and Informing Notice, TEMP 2190 (6/01) - Important Notice For CalWORKs Recipients (Multilingual), TEMP 2190 (6/01) - Important Notice For Calworks Recipients (Multilingual), TEMP 2201 (7/02) - Cash Aid/Food Stamp Electronic Benefit Transfer - EBT Request For A Designated Alternate Card Holder/Authorized Representative, TEMP 2202 (7/02) - Cash Aid/Food Stamp Electronic Benefit Transfer - EBT Service Request, TEMP 2203 (7/02) - Request For Cash Aid Electronic Benefit Transfer - EBT Exemption, TEMP 2214 (7/08) - Additional Information About Electric Benefit Transfer (EBT), TEMP 2229 (3/07) ENG/SP - Important Notice - KinGAP Informing Notice, TEMP 2232 (4/08) - Notice of Possible Listing on the Child Abuse Central Index, TEMP 2250 (7/19) - State Law Changes Maximum Aid Payment (MAP) Levels For Cash Aid Recipients, TEMP 2252 (7/19) - State Law Changes The CALWORKs Earned Income Disregard, TEMP 2316 (2/20) - Sick Leave Yearly Notification, TEMP 3005 (12/14) - Changes For People With A Prior Felony Drug Conviction, TEMP 3013 - (5/18) CFT Professional Brochure, TEMP 3014 - (2/20) Treasury Offset Program (TOP) Pre-Offset Notice, TEMP 3015 - (2/20) Franchise Tax Board (FTB) Pre-Offset Notice, TEMP 3015A (2/20) - Franchise Tax Board (FTB) Annual Pre-Offset Notice, TEMP 3017 - (2/20) - Treasury Offset Program Notification Of Offset, TEMP CF 1468 (2/15) - CalFresh Notice Of Change, TEMP M40-107A (9/11) - CalWORKs 48-Month Time Limit Time On Aid (Unticking Months Due To Temporary Exemptions), TEMP M40-107E (4/11) - Change CalWORKs Time Limit 48th Month On Aid, TEMP M40-107G (4/11) - Discontinue CalWORKs Time Limit/Income Exceeds, TEMP M40-107H (4/11) - Change CalWORKs Time Limt 40th Month On Aid-MFG Child, TEMP M40-107I (4/11) - Discontinue CalWORKs Time Limit 48th Month On aid, No Eligible Child, TEMP M40-107J (4/11) - Partial Approval CalWORKs Time Limit Timed-Out Adult, TEMP NA 1225 (8/01) - Underpayment Computation, TEMP NA 1231 (5/02) - Continuation Page - Underpayment computation Pre 1/1/98- Required Form- No Substitute Permitted, TEMP NA 1232 (6/11) - Notice of Action - CalFresh EBT Account, TEMP NA 1236 (9/02) - Retroactive Eligibility - Deny (MBSAC), TEMP NA 1238 (7/04) - Food Stamp Notice - EBT Account Adjustment, TEMP W&I 11450.025 (5/11) - Incremental Grant Reduction, TEMP W&I 11450.025A (5/11) - Incremental Grant Reduction, TEMP WI 10072 (8/13) - EBT Replacement Approval, TEMP WI 10072A (8/13) - EBT Replacement Review, TILP 1 (7/18) - Transitional Independent Living Plan & Agreement, TLR 1 (12/15) - Trustline Registry "The California Registry Of In-Home Child Care Providers" - Subsidized Application, TLR 2 (12/15) - Trustline Registry "The California Registry Of In-Home Child Care Providers" - In-Home/License Exempt Child Care Provider Application, TLR 4 (2/16) - TrustLine Registry "The California Registry of In-Home and License-Exempt Child Care Providers" Ancillary Day Care Center, TLR 301E (3/11) - Trustline Reference Request - Exemption, TLR 508 (10/09) - Trustline Registry Criminal Record Statement, TLR 9163 (12/15) - Request For Live Scan Service for Subsidized TrustLine Registry Applicants, TLR 9163A (10/15) - Request for Live Scan Service for TrustLine Registry Applicants, TM44-111A - (4/13) - Income Disregards Change, TM44-315D (4/11) - 8 Percent Grant Reduction Change, TM44-315E (4/11) - Grant Reduction And Income Disregard Discontinue, TM44-315F (4/11) - Grant Reduction And Income, TM44-315G (12/13) - Law Change To MAP Levels, TM44-315H (9/14) - Law Change To MAP Levels, TM44-315I (8/16) - Law Change to MAP levels, TM44-315K (7/19) - Law Change To MAP Levels, TNB 1 (8/18) - Notice To CalFresh Recipients Transitional Nutrition Benefit (TNB) Program, TNB 2 (8/18) - Notice Of Approval For Transitional Nutrition Benefit (TNB) Program, TNB 3 (8/18) - Notice Of Change For Transitional Nutrition Benefit (TNB) Program, TNB 4 (8/20) - Notice Of Recertification For Transitional Nutrition Benefit (TNB) Program, TNB 5 (8/18) - Recertification Reminder Notice For Transitional Nutrition Benefit (TNB) Program Recertification Form Not Received Or Incomplete, TNB 6 (8/18) - Notice Of Discontinuance For Transitional Nutrition Benefit (TNB) Program, TNB 7 (6/19) - Transitional Nutrition Benefit (TNB) Informing Notice Of Receiving Intercounty Transfer, TNB 8 (6/19) - Transitional Nutrition Benefit (TNB) Informing Notice Of Sending Intercounty Transfer, WI 10072A (12/18) - EBT Replacement Approval, WI 10072B (12/18) - EBT Replacement Review, WINS 1 (5/14) - Notice To All CalFresh Recipients Work Incentive Nutritional Supplement (WINS) Benefit Important - Please Read, WINS 1239 (5/14) - CalFresh Notice Of Approval/Denial/Termination Work Incentive Nutritional Supplement (WINS) Benefits, WTW 1 (12/05) - Welfare To Work Plan Rights and Responsibilities, WTW 2 (12/12) - Welfare to Work Plan Activity Assignment, WTW 5 (9/13) - Welfare-To-Work Program Notice - Tell The County If You Need Help Reading Or Understanding This Notice, WTW 8 (6/04) - STUDENT FINANCIAL AID STATEMENT - WELFARE TO WORK SUPPORTIVE SERVICES, WTW 9 (7/99) - WELFARE TO WORK APPRAISAL APPOINTMENT LETTER, WTW 10 (7/99) - REQUEST FOR WELFARE TO WORK THIRD-PARTY ASSESSMENT, WTW 11 (7/99) - Welfare to Work/Cal-Learn Supportive Service Overpayment/Underpayment Notice, WTW 12 (7/99) - Welfare to Work/Cal-Learn Supportive Service Repayment Agreement, WTW 13 (7/99) - Welfare to Work/Cal-Learn Supportive Service Overpayment Final Notice, WTW 15 (9/13) - Simplified CalFresh Program Unpaid Work Experience (WEX) And Unpaid Community Service Hours Worksheet, WTW 16 (12/05) - Grant-Based On-The-Job Training Participation: Voluntary Consent Form, WTW 16A (7/19) - Grant Based OJT Income Examples For Region 1 - Use Starting June 1, 2020, WTW 16B (7/19) - Grant Based OJT Income Examples For Region 2 - Use Starting June 1, 2020, WTW 17 (12/15) - Waiver Of CalWORKs Learning Disabilities Screening And/Or Evaluation, WTW 20 (12/05) - Permission To Release Learning Disabilities Information, WTW 26 (8/15) - Good Cause Determination Guidelines, WTW 27 (10/03) - Request For Good Cause Determination, WTW 29 (8/15) - Plan To Meet Welfare To Work Rules And Get My Cash Aid Back, WTW 31 (8/15) - Request To Meet Welfare To Work Rules To Get My Cash Aid Back, WTW 32 (10/03) - Welfare To Work Compliance Plan, WTW 34 (4/04) - Welfare To Work Family Reunification Plan, WTW 37 (7/09) - Permission To Release Domestic Abuse Information When Moving To Another County, WTW 38 (6/13) - Welfare-To-Work 24-Month Time Clock Notice, WTW 43 (9/14) - Notice Of Your Welfare-To-Work (WTW) 24-Month Time Clock Ending Soon, WTW 44 (1/15) – Welfare To Work (WTW) 24-Month Time Clock Extension Request Form, WTW 45 (1/15) – Welfare To Work (WTW) 24-Month Time Clock Extension Determination, WTW 46 (1/15) - End?Of Welfare-To-Work 24-Month Time Clock Review Appointment Letter, WTW 47 (3/15) - Online CalWORKs Appraisal Tool Rights And Privacy, WTW 48 (7/16) - Learning Needs Screening (Spanish), WTW 49 (4/16) - Learning Needs Screening – Client Copy (Spanish), WTW EOA 1 (11/17) - CalWORKs Educational Opportunity and Attainment (EOA) Program Application Form, WTW EOA 2 (12/17) - CalWORKs Educational Opportunity and Attainment (EOA) Program Approve Form, WTW EOA 3 (12/17) - Notice of Action CalWORKs Educational Opportunity and Attainment (EOA) Program Deny Form.

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