2011 Notice Of Forms Changes

  • 11-161
    KG 1 (12/11)  Kin-GAP Mutual Agreement for 18 year olds
  • 11-160
    SOC 369A (11/11)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment
  • 11-159
    PUB 428 (11/11) English and Spanish - It's Your Money - Claim It and Save It - Brochure
    PUB 429 (11/11) English and Spanish - It's Your Money - Claim It and Save It - Flyer
  • 11-158
    SOC 875 (11/11) IHSS Program Notice To Recipient Of Health Care Certification Requirement
  • 11-157
    SOC 874 (11/11) IHSS Program Notice To Applicant Of Health Care Certification Requirement
  • 11-156
    SOC 873 (11/11) IHSS Program Health Care Certification Form
  • 11-155
    TEMP 2257 (11/11) IHSS Program Notice To Recipient Of Reduction In Authorized Hours
  • 11-154
    TEMP 2256 (11/11)  IHSS Program Notice To Recipient Of Exemption From Reduction In Service Hours
  • 11-153
    LIC 422 (9/11)  Notice of Civil Penalties Due
  • 11-152
    SOC 877 (11/11)  In-Home Supportive Services (IHSS) Program Application For Supplemental Care
  • 11-151
    AAP 5 (11/11)  Adoption Assistance Program Independent Adoptions Program Statement of Acknowledgement
  • 11-150
    CW 86 (9/11) English and Spanish - Agreement-Restricted Account CalWORKs Program
  • 11-149
    SOC 880 (11/11) Safely Surrendered Baby - Report To The California Department Of Social Services
  • 11-148
    SOC 163 (11/11)  Voluntary Re-Entry Agreement For Extended Foster Care
  • 11-147
    SOC 162 (10/11)  Mutual Agreement For Extended Foster Care 
  • 11-146
    SOC 161 (9/11)  Six-Month Certification Of Extended Foster Care Participation
  • 11-145
    AD 927 (9/11)  Statement of Understanding - Independent Adoptions Program -- Indian Child
  • 11-144
    SOC 369A (10/11) Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment
  • 11-143
    LIC 602A (8/11)  Physician's Report For Residential Care Facilities For The Elderly (RCFE)
  • 11-142
    PUB 456 (3/11)  English and Spanish - Important Information For Relatives
  • 11-141
    SOC 876 (10/11) IHSS Program Notice Of Provisional Approval Health Care Certification Exception Granted
  • 11-140
    PUB 411 (8/11) - 20 Facts About Child Abuse And Neglect (paper size 9" x 12" printed landscape)
  • 11-139
    LIC 9200 (9/11)  Pre-Licensing Facility Evaluation Checklist
  • 11-138
    LIC 9020 (8/11)  Register of Facility Clients/Residents
  • 11-137
    LIC 195A (8/11)  Notice of Operation In Violation Of Law - Family Child Care Home
  • 11-136
    LIC 195 (8/11) Notice Of Operation In Violation Of Law
  • 11-135
    NA 1263 (8/11) English and Spanish - Notice Of Action - Overissuance Budget Worksheet
  • 11-134
    SOC 858 (9/11) English and Spanish IHSS Provider Notification
  • 11-133
    SOC 831 (10/11) IHSS Provider Letter
  • 11-132
    SOC 829 (10/11) IHSS Provider Direct Deposit Enrollment/Change/Cancellation Form
  • 11-131
    SOC 404 (10/11) English and Spanish IHSS Program Direct Deposit Enrollment/Change/Cancellation Form
  • 11-130
    QR 377.2 (10/11) CalFresh Notice Of Expiration Of Certification
  • 11-129
    DFA 387 (10/11) CalFresh Request For Information
  • 11-128
    DFA 386 (10/11) CalFresh Notice Of Missed Interview
  • 11-127
    DFA 1239 (10/11) CalFresh Notice Of Approval/Denial/Termination Transitional Benefits
  • 11-126
    FS 29 (10/11) CalFresh Recertification Appointment Letter
  • 11-125
    TEMP WTW 5 (8/11) Welfare-To-Work Progam Notice
  • 11-124
    TEMP CW 2186C (8/11) English and Spanish - CalWORKs Exemption Request For Welfare-To-Work Teen Parents
  • 11-123
    TEMP M42-769 (8/11) English and Spanish - Approve School Bonus
  • 11-122
    TEMP CL 10 (8/11) English and Spanish - Welfare-to-Work Teen Parent Notice Of Exemption
  • 11-121
    TEMP CL 8 (8/11) English and Spanish - Welfare-To-Work Teen Parent Notice Of Report Card Submittal Schedule
  • 11-120
    TEMP CL 4 (8/11) English and Spanish - Welfare-To-Work Teen Parent Informing Notice To Parent/Legal Guardian Of Welfare-To-Work Participant
  • 11-119
    TEMP CL 2 (8/11) English and Spanish - Welfare-To-Work Program Requirements
  • 11-118
    TEMP CL 1 (8/11) English and Spanish - Welfare-To-Work Program Information Orientation Appointment Notice
  • 11-117
    WTW 15 (9/11) Simplified Food Stamp Program Unpaid Work Experience
  • 11-116E
    SAWS 2A QR (9/11) Rights, Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, and/or Medi-Cal/34-County Medical Services Program
  • 11-116
    SAWS 2A QR (9/11) Rights, Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, and/or Medi-Cal/34-County Medical Services Program
  • 11-115
    CW 2166 (9/11) Multilingual Work Really Pays! Here's How - Work Pays Notice
  • 11-114
    NA 200 (9/11) Notice Of Action - Multipurpose - Incl Budget
  • 11-113
    NA 271 (9/11) Notice Of Action - Family's Income
  • 11-112
    NA 300 (9/11) Notice Of Action - Recipient - Financial Eligibility Tests
  • 11-111
    NA 531 (9/11) Notice Of Action 48-Month Time Limit (Continued) Adult Reached CalWORKs 48-Month Time Limit
  • 11-110
    NA 1239 (9/11) Notice Of Action Continued Quarterly Reporting Budget
  • 11-109
    QR 30 (9/11) CalWORKs Budget Worksheet
  • 11-108
    TEMP NA BACK (9/11) Your Hearing Rights
  • 11-107
    AAP 8 (7/11) English and Spanish - Adoptions Assistance Program Nonrecurring Adoption Expenses Agreement
  • 11-106
    AD 521 (8/11) Application For Adoption Of A Child
  • 11-105
    AD 904 (7/11) English and Spanish - Consent For Contact
  • 11-104
    AD 929 (8/11) Waiver Of Right To Revoke Consent Independent Adoption Program
  • 11-103
    AD 4320 (8/11) Adoption Assistance Program (AAP) Agreement
  • 11-102
    DFA 385 (9/11) Application For Disaster CalFresh
    DFA 390 (9/11) Notice Of Approval/Denial  For Disaster CalFresh
  • 11-101
    FS 11 (9/11) ENG/SP Notice To All CalFresh Recipients Important - Please Read
  • 11-100
    AD 930 (7/11) Independent Adoption Placement Agreement Transmittal
  • 11-099 
    LIC 602 (7/11) Physician's Report For Community Care Facilities
  • 11-098
    FC 8 (7/11)  Federal Eligibility Certification For Adoption Assistance Program
  • 11-097
    AAP 4 (7/11)  Eligibility Certification Adoption Assistance Program 
  • 11-096
    AAP 3 (7/11)  Reassessment Information Adoption Assistance Program
  • 11-095
    AAP 2 (7/11)  Payment Instructions Adoption Assistance Program
    AAP 6 (7/11)  Adoption Assistance Program Negotiated Benefit Amount and Approval
  • 11-094
    LIC 9163B  (7/11)  Request For Live Scan Service - Long Term Care Ombudsman
  • 11-093
    PUB 13 (6/11)  Eng/SP   Your Rights Pamphlet (Requires 8 1/2" x 14" paper printed landscape)
  • 11-092
    LIC 422A (7/11)  Civil Penalty Ledger
  • 11-091
    LIC 422 (7/11)  Notice of Civil Penalties Due
  • 11-090
    LIC 421C (7/11)  Civil Penalty Assessment - Immediate $150
  • 11-089
    LIC 421A (7/11)  Civil Penalty Assessment (Unlicensed Facility)
  • 11-088
    LIC 421 (7/11)  Civil Penalty Assessment
    LIC 421B (7/11)  Civil Penalty Assessment - Immediate
  • 11-087
    LIC 178 (7/11)  Penalty Review
  • 11-086
    QR 285B (8/11) CalFresh Budget Worksheet/Quarterly Reporting Households
    DFA 285B (8/11) CalFresh Budget Worksheet/Change Reporting Household
    DFA 285D (8/11) CalFresh Budget Worksheet - Special Medical/Shelter Deductions
  • 11-085
    DFA 377.7D3 (6/11) English and Spanish - CalFresh Overissuance Notice For Administrative Errors Only
  • 11-084
    PUB 275 (4/07) Family Planning - Making The Commitment For A Healthy Future
  • 11-083
    PUB 111 (8/11) Deaf Access Program Brochure
  • 11-082
    SOC 873 (7/11) IHSS Program Medical Certification Form
    SOC 874 (7/11) IHSS Program Notice To Applicant Of Medical Certification Requirement
    SOC 875 (7/11) IHSS Program Notice To Recipient Of Medical Certification Requirement
  • 11-081
    TEMP CW 2186A (7/11) CalWORKs Time Limit And Welfare-To-Work Participation Exemption Request Form
  • 11-080
    CW 2184 (7/11) CalWORKs 48-Month Time Limit
  • 11-079
    SOC 831 (7/11) IHSS Provider Letter
  • 11-078
    CW 2186B (4/11) English and Spanish - CalWORKs and Welfare To Work Time Limit Exemption Determination
  • 11-077
    NA 835 (4/11) English and Spanish - Notice Of Action Child Care Discontinuance
  • 11-076
    NA 1267 (4/11) CalFresh Informing Notice Of Receiving Intercounty Transfer
    NA 1268 (4/11) CalFresh Informing Notice Of Sending Intercounty Transfer
  • 11-075
    CW 101 (6/11) English and Spanish - CalWORKs Immunization Rules
  • 11-074
    WTW 16B (6/11) Grant-Based OJT Income Examples For Region 2
  • 11-073
    WTW 16A (6/11) Grant-Based OJT Income Examples For Region 1
  • 11-072
    NA 281A (6/11) Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 7-1-2011)
  • 11-071
    NA 281 (6/11) Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 1-1-98 thru 6-30-2011)
  • 11-070
    NA 274F (6/11) Notice Of Action Overpayment Amount Owed (For Overpayments Occurring On Or After 7-1-2011)
  • 11-069
    NA 274E (6/11) Notice Of Action Overpayment Amount Owed (For Overpayments Occurring On Or After 1-1-98 through 6-30-2011)
  • 11-068
    CW 2192 (6/11) Tracking Non-California TANF Assistance For Time Limits
  • 11-067
    CW 2191 (6/11) Time On Aid Verification For CalWORKs/TANF 48-Month Time Limits
  • 11-066
    CW 2190B (6/11) CalWORKs 48-Month Time Limit Extender Determination Denial Form
  • 11-065
    CW 2190A (6/11) CalWORKs 48-Month Time Limit Extender Request Form
  • 11-064
    CW 2189 (6/11) Notice Of Your CalWORKs Time Limit - 42nd Month On Aid
  • 11-063
    CW 88 (6/11) Diversion Services Agreement CalWORKs Program
  • 11-062
    CW 88 Coversheet (6/11) You May Be Eligible For Diversion Services
  • 11-061
    TEMP NA 1232 (6/11) CalFresh Notice Of Action - EBT Account
  • 11-060
    FS 27 (3/10) Non-Assistance Food Stamps (NAFS) Household Recertification Form
  • 11-059
    CW 2184 (4/11) CalWORKs 48-Month Time Limit On Aid
    CW 2187 (4/11) Your CalWORKs 48-Month Time Limit/Information About Your CalWORKs 48-Month Time Clock
    TEMP CW 2186A (4/11) CalWORKs Time Limit and Welfare-To-Work Participation Exemption Request Form
  • 11-058
    NA 530 (4/11) Notice of Action - 48-Month Time Limit
    NA 531 (4/11) Notice of Action - Adult Reached CalWORKs 48-Month Time Limit (Continued)
    NA 532 (4/11) Notice of Action - 48-Month Time Limit (Continued) Adult Reached CalWORKs 48-Month Time Limit - Discontinue
  • 11-057
    NA BACK 9 (Revised 4/2011)  English and Spanish Your Hearing Rights
  • 11-056
    TEMP 2253 (4/11) You Are Required To Participate In Welfare-To-Work
    TEMP 2254 (4/11) State Law Has Changed The Cal-Learn Program New Rules
  • 11-055
    TEMP 2251 (4/11) English and Spanish New State Law Rules In CalWORKs Starting July 1, 2011
  • 11-054
    AAP 8 (1/11) Adoptions Assistance Program Nonrecurring Adoption Expenses Agreement
  • 11-053
    TEMP CW 2185 (2/02) What you Should Know About The CalWORKs 60-Month Time Limit
  • 11-052
    TEMP 2250 (4/11) State Law Changes MAP Levels For Cash Aid Recipients
    TEMP 2252 (4/11) State Law Changes The CalWORKs Income Disregards
  • 11-051
    NA 200 (4/11) Notice Of Action - Multipurpose - Incl Budget
  • 11-050
    TEMP 2234 (4/09), TEMP 2160 (6/03) and TEMP 2160A (6/03)
  • 11-049
    TLR 9163A (3/11)  Request For Live Scan Service For TrustLine Registry Applicants
  • 11-048
    TLR 9163 (3/11)  Request For Live Scan Service For Subsidized TrustLine Registry Applicants
  • 11-047
    TLR 301E (3/11)  TrustLine Reference Requests
  • 11-046
    TLR 4 (3/11)  TrustLine Registry - "The California Registry Of In-Home And License-Exempt Child Care Providers" Ancillary Day Care Center
  • 11-045
    SOC 369A (3/11)  Kinship Guardianship Assistance Payment (KIN-GAP) Program Agreement Amendment
  • 11-044
    LIC 9194 (3/11)  Live Scan Instructions For State Licensed Facilities
  • 11-043
    LIC 9163B (3/11)  Request For Live Scan Service - Long Term Care Ombudsman - Applicant Submission
  • 11-042
    LIC 9163 (3/11)  Request For Live Scan Service - Community Care Licensing - Applicant Submission
  • 11-041
    LIC 508D (3/11)  Out-Of-State Disclosure & Criminal Record Statement - Foster Family Homes, Small Family Homes, Certified Family Homes
  • 11-040
    LIC 508B (3/11)  Criminal Record Statement - Long-Term Care Ombudsman Program
  • 11-039
    LIC 508A (3/11)  Criminal Record Statement - Adoption Facilitator
  • 11-038
    LIC 508 (3/11)  Criminal Record Statement
  • 11-037
    LIC 198B (3/11)  Out-Of-State Child Abuse/Neglect Report Request
  • 11-036
    LIC 198A (3/11)  Child Abuse Central Index Check For State Licensed Facilities
  • 11-035 (not used)
  • 11-034
    AD 908A (1/11) Adoptions Information Act Statement
  • 11-033
    FC 8 (1/11) Federal Eligibility Certification For Adoption Assistance Program
  • 11-032
    SSP 14 (9/10) English and Spanish - Authorization For Reimbursement Of Interim Assistance Initial Claim Or Posteligibility Case
  • 11-031
    TEMP 2245 (1/11) Multilingual Important Information About Electronic Benefit Transfer (EBT)
  • 11-030
    DFA 377.7F (2/11) CalFresh Overissuance Notice For an Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IPV
  • 11-029
    DFA 377.7D3 (2/11) CalFresh Overissuance Notice for Administrative Errors Only
  • 11-028
    DFA 377.7D1 (2/11) CalFresh Overissuance Notice For Administrative Errors Only
  • 11-027
    DFA 377.7B (2/11) CalFresh Overissuance Notice For Inadvertent Household Errors Only
  • 11-026
    DFA 377.7D (2/11) CalFresh Overissuance Notice For Administrative Errors Only
  • 11-025
    SOC 369A (3/11)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment
  • 11-024
    SOC 818  (12/10) English & Spanish  - Relative Or Non-Relative Extended Family Member Caregiver Assessment
  • 11-023
    SOC 817  (12/10) Checklist Of Health and Safety Standards For Approval Of Family Caregiver Home
  • 11-022
    SOC 815  (12/10) Approval Of Family Care Giver Home
  • 11-021
    DFA 285B (2/11) CalFresh Budget Worksheet/Change Reporting Households
  • 11-020
    QR 285B (2/11) CalFresh Budget Worksheet/Quarterly Reporting Households
  • 11-019
    TLR 3 (2/11)  TrustLine To Community Care Licensing Criminal Background Clearance Transfer Request
  • 11-018
    TLR 2 (2/11)  TrustLine Registry - "The California Registry Of In-Home Child Care Providers"
    - In-Home/License Exempt Child Care Provider Application
  • 11-017 
    TLR 1 (2/11)  TrustLine Registry - The California Registry Of In-Home Child Care Providers Subsidized Application
  • 11-016
    LIC 9092  (2/11)  Fire Pre-Inspection/Consultation Request
  • 11-015
    LIC 9020 (2/11)  Register Of Facility Clients/Residents
  • 11-014
    LIC 184B  (12/10)  Notification Of Incomplete Application (Family Child Care Home)
  • 11-013
    LIC 200 (2/11)  Application For A Community Care Facility Or Residential Care Facility For The Elderly License
  • 11-012
    KG 2 (1/11)  Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program
  • 11-011
    SOC 369A (12/10)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment
  • 11-010
    SOC 369 (12/10)  Agency-Relative Guardianship Disclosure
  • 11-009
    CW 51 (12/10) Child Support - Good Cause Claim For Noncooperation
  • 11-008
    SOC 426C (10/10) IHSS Program California Code Sections
  • 11-007
    SOC 426 (1/11)  IHSS Program Provider Enrollment Form
  • 11-006
    SOC 848, SOC 851, SOC 852, SOC 854, SOC 855, SOC 856 (1/11)
    In-Home Supportive Services Program
  • 11-005
    SOC 847, SOC 852A, SOC 855A, SOC 855B, SOC 857, SOC 858A, SOC 858B, SOC 859A, SOC 859B, SOC 862, SOC 863 (1/11)
    In-Home Supportive Services Program
  • 11-004 (not used)
  • 11-003
    SAWS 2A QR (11/10) Rights and Responsibilities and Other Important Information
  • 11-002
    PUB 69 (9/10) County Forms Catalog 2010-11
  • 11-001
    LIC 9058 (1/11) Applicant/Licensee Rights