Armenian

Armenian Translations

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Note: Almost all form translations are done into Eastern Armenian. These forms are labelled “Armenian” in the document footer. Forms translated into Western Armenian are clearly labelled in the form link. Those forms also show “Armenian (Western)” in the footer.

For Armenian forms beginning with the following letters:

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |

Forms translated into ARMENIAN

A

• ABCD 478A (5/20) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• ABCDM 229 (1/23) - Applicant/Recipient’s Authorization For Release Of Information To Community-Based Organization (CBO) In BenefitsCal
• AD 501 (4/24) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father In California)
• AD 885A (4/22) - Statement Of Understanding Agency Adoption Program - Parent Or A Presumed Parent Of A Child Who Is Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian
• AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh
• AR 3 (2/15) - Mid-Year Status Report For CalWORKs and CalFresh

C

• CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers)
• CCP 7 (1/26) - CalWORKs Child Care Request Form And Child Care Payment Rules
• CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form
• CF 1 (9/25) - Notice To All CalFresh Recipients - Important Please Read
• CF 10 (12/13) - Dependent Care Cost Affidavit
• CF 11 (9/24) - Notice To All CalFresh Recipients - Use Until September 30, 2025
• CF 11 (9/25) - Notice To All CalFresh Recipients - Use Starting October 1, 2025
• CF 12 (1/25) - Notice to CalFresh Recipients
• CF 18 (2/14) ENG/Armenian - Important Information
• CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits
• CF 21 (3/14) - Release Form
• CF 28 Coversheet (2/14) - CalFresh Program Restricted Account Coversheet - Important To Know
• CF 28A (2/14) - CalFresh Program Restricted Account Agreement Part A
• CF 28B (2/14) - CalFresh Program Restricted Accounting Agreement part B
• CF 30 (2/18) - SAR 7 Reminder Notice
• CF 30 LP (2/18) - SAR 7 Reminder Notice - Large Print
• CF 31 (6/19) - CalFresh Supplemental Form For Special Medical Deductions
• CF 32 (6/13) - CalFresh Request For Contact
• CF 37 (11/16) - Recertification For CalFresh Benefits
• CF 100 (11/20) - CalFresh Request For Authorized Representative Drug Or Alcohol Treatment Center Resident
• CF 101 (11/20) - CalFresh Request For Authorized Representative
• CF 211 (6/23) – CalFresh Notice of Provider Determination
• CF 285 (8/21) - Application For CalFresh Benefits
• CF 285A (11/21) - Application For CalFresh Benefits
• CF 303 (7/24) – Replacement Or Disaster Supplement Affidavit
• CF 377.1 (8/24) - Notice Of Approval For CalFresh Benefits
• CF 377.1A (8/24) - Notice Of Denial Or Pending Status
• CF 377.10 (2/24) - CalFresh Notice Of Denial/Disqualification For Failure To Meet General CalFresh Work Rules
• CF 377.11 (8/25) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement
• CF 377.11A (8/25) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11B (8/25) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11D (1/20) – CalFresh Discretionary Exemption For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11E (8/25) – CalFresh Able-Bodied Adult Without Dependents (ABAWD) Time Limit Exemption Screening Form
• CF 377.2 (9/18) - CalFresh Notice Of Expiration Of Certification
• CF 377.2B (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members
• CF 377.2C (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members
• CF 377.2D (3/18) - CalFresh Notice Of Status Change For Households With Only Elderly And/Or Disabled Members
• CF 377.4 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households
• CF 377.4 SAR (8/24) - CalFresh Notice Of Change For Semi-Annual Reporting Households
• CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report
• CF 377.6 (8/13) - Information/Verification Needed
• CF 377.7A (2/14) - Notice Of Administrative Disqualification
• CF 377.7A1 (2/14) - Request For Restoration Of CalFresh Benefits After Administrative
• CF 377.7B (6/22) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only
• CF 377.7B LP (6/22) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only - Large Print
• CF 377.7B LP (6/22) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only - Large Print
• CF 377.7C (2/14) - CalFresh Repayment Agreement For Inadvertent Household Errors Only
• CF 377.7D (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only
• CF 377.7D1 (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only
• CF 377.7D2 (6/22) - CalFresh Repayment Final Notice - County Administrative Error (AE)
• CF 377.7D2 LP (6/22) - CalFresh Repayment Final Notice - County Administrative Error (AE) - Large Print
• CF 377.7D3 (6/22) - CalFresh Overissuance Notice For Administrative Errors (AE)
• CF 377.7D3 LP (6/22) - CalFresh Overissuance Notice For Administrative Errors (AE) - Large Print
• CF 377.7E1 (1/14) - CalFresh Repayment Agreement For Administrative Errors Only
• CF 377.7F (10/17) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV)
• CF 377.7F LP (2/18) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV) - Large Print
• CF 377.7F1 (10/17) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV)
• CF 377.7F1 LP (2/18) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV) - Large Print
• CF 377.7G (3/18) - CalFresh Intentional Program Violation (IPV) Notice - Due To Trafficking
• CF 377.7H (2/23) - CalFresh Informational Notice - Potential Intentional Program Violation (IPV)
• CF 377.9 (8/20) - Notice Of Back CalFresh Benefits
• CF 377.9LP (8/20) - Notice Of Back CalFresh Benefits - Large Print
• CF 385 (1/24) - Application For Disaster CalFresh
• CF 386 (2/14) - CalFresh Notice Of Missed Interview
• CF 387 (5/14) - CalFresh Request For Information
• CF 388 (7/25) - CalFresh Notice Of Restoration Approval
• CF 389 (7/25) - Notice Of Denial Of Restoration
• CF 478 (2/14) - Disqualifiction Consent Agreement CalFresh Program
• CF 485 (10/23) - CalFresh Elderly Simplified Application
• CF 485 LP (12/23) - CalFresh Elderly Simplified Application - Large Print
• CF 886 (8/25) - CalFresh Notice Of Work Rules
• CF 887 (5/25) - CalFresh Medical Certification Form
• CF 888 (5/25) - CalFresh Able-Bodied Adults Without Dependents Volunteer Work Hours Verification Form
• CF 889 (6/25) - CalFresh Restaurant Meals Program Approval/Termination Notice of Action
• CF 890 (6/25) - CalFresh Employment and Training Civil Rights Notice
• CF 1239 (12/20) - CalFresh Notice Of Approval/Denial/Termination Transitional Benefits
• CF 6177 (10/22) - CalFresh Student Exemption Screening Form
• CF SSA 1 (7/24) - Information For Households Applying For CalFresh With The Social Security Administration
• CF SSA 1 LP (7/24) - Information For Households Applying For CalFresh With The Social Security Administration - Large Print
• CFAP 377.7B (9/25) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2027
• CFAP 377.7B1 (9/25) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2027
• CFAP 377.7C (9/25) – California Food Assistance Program (CFAP) - State CalFresh Repayment Agreement For Inadvertent Household Errors (IHE) - Use Starting October 1, 2027
• CFAP 377.7D2 (9/25) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice County Administrative Error (AE) - Use Starting October 1, 2027
• CFAP 377.7D3 (9/25) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice County Administrative Error (AE) - Use Starting October 1, 2027
• CFAP 377.7E1 (9/25) – California Food Assistance Program (CFAP) — State CalFresh Repayment Agreement For Administrative Errors - Use Starting October 1, 2027
• CFAP 377.7F (9/25) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV) - Use Starting October 1, 2027
• CFAP 377.7F1 (9/25) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice Intentional Program Violation (IPV) - Use Starting October 1, 2027
• CFAP 377.7F2 (9/25) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Intentional Program Violation (IPV) - Use Starting October 1, 2027
• CFAP 377.7G (9/25) – California Food Assistance Program (CFAP) - State CalFresh Intentional Program Violation (IPV) Notice Due To Trafficking - Use Starting October 1, 2027
• CFAP 377.7G2 (10/25) – California Food Assistance Program (CFAP) Repayment Agreement For An Intentional Program Violation (IPV) Only - Use Starting October 1, 2027
• CFAP 377.7H (9/25) – California Food Assistance Program (CFAP) - State CalFresh Informational Notice Potential Intentional Program Violation (IPV) - Use Starting October 1, 2027
• CFAP 377.7T (9/25) – CalFresh/California Food Assistance Program (CFAP) State CalFresh Overissuance Repayment Agreement Transition Notice - Use Starting October 1, 2027
• CL 2 (5/25) - Cal-Learn Program Requirements
• CL 3 (5/25) - Cal-Learn Notice Of A Participation Problem
• CL 4 (4/25) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant
• CL 8 (5/25) - Cal-Learn Notice Of Report Card Submittal Schedule
• CL 10 (5/25) - Cal-Learn Notice Of Exemption/Deferral
• CL 11 (4/25) - Cal-Learn Notice Of Incomplete Grades
• CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement
• CSFP 001 (7/22) - Commodity Supplemental Food Program (CSFP) Participant Application
• CSFP 006 (7/22) - Commodity Supplemental Food Program (CSFP) Notice Of Action
• CSFP 010 (6/23) Commodity Supplemental Food Program (CSFP) Proxy Designation Form
• CSFP 011 (7/23) – Commodity Supplemental Food Program (CSFP) Alternate (PROXY) Pick Up Form
• CTRI 01 (10/20) - California Tax Return Information (CTRI) Notification To Client
• CW 8 (11/14) - Statement of Facts For An Additional Person
• CW 30 (12/23) – CalWORKs Budget Worksheet - Use Starting June 1, 2020
• CW 42 (9/23) - Statement of Facts - Homeless Assistance
• CW 8A (12/14) - Statement Of Facts To Add A Child Under 16
• CW 52 (10/20) – California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Instead Of Cash Grant Option
• CW 63 (11/20) - Request For Income And/Or Resource Verification
• CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs
• CW 105 (12/25) - Pregnancy Verification
• CW 215A (1/25) - CalWORKs Intercounty Transfer Continuation Request For Additional Documents
• CW 377 (12/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV)
• CW 2166 (4/21) - Multilingual Work Really Pays! Here's How - Use Starting May 1, 2022
• CW 2166 (11/21) - Multilingual Work Really Pays! Here's How - Use Starting June 1, 2022
• CW 2184 (1/24) - CalWORKs 60-Month Time Limit - Use Starting October 1, 2024
• CW 2186A (1/24) - CalWORKs Exemption Request Form - Use Starting October 1, 2024
• CW 2186A (4/21) - CalWORKs Exemption Request Form - Use Starting May 1, 2022
• CW 2186B (4/21) - CalWORKs Exemption Determination - Use Starting May 1, 2022
• CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit - Use Starting May 1, 2022
• CW 2189A (9/20) – Notice Of Your CalWORKs Time Limit – 54TH Month On Aid (Use Starting May 1, 2022)
• CW 2189B (9/20) – Notice Of Your CalWORKs Time Limit – 57TH Month On Aid (Use Starting May 1, 2022)
• CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form - Use Starting May 1, 2022
• CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form - Use Starting May 1, 2022
• CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits - Use Starting May 1, 2022
• CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits - Use Starting May 1, 2022
• CW 2200 (5/23) - Request For Verification
• CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed
• CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change
• CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs
• CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case
• CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child) - Use Starting June 1, 2022 

D

• DFA 377.1 (11/01) - Notice of Approval
• DFA 377.1A (3/02) - Notice Of Denial Or Pending Status
• DFA 377.7A (4/21) - Notice Of Administrative Disqualification
• DFA 377.7D2 (10/00) - Food Stamp Repayment Notice For Administrative Errors Only Final Notice
• DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only
• DFA 377.7F (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV)
• DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV) - Large Print
• DFA 377.7G (5/02) - Food Stamp Repayment Agreement For An Intentional Program Violation (IPV) Only
• DFA 377.7F1 (10/00) - Food Stamp Repayment Notice For An Intentional Program Violation (IPV) Only Final Notice
• DPA 19 (6/22) - Appointment Of Authorized Representative
• DPA 315 (2/25) - Withdrawal/Conditional Withdrawals Of Request For Hearing
• DPA 436B (8/18) - County Information Letter

E

• EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account
• EBT 2216 (4/23) - EBT Surcharge Free - Direct Deposit Handout
• EBT 2259 (3/24) - Report Of Electronic Theft Of Benefits
• EBT 2259A (11/21) - EBT Scamming Acknowledgement
• EBT 2260 (8/21) - Excessive Card Replacement Warning Letter
• EFA 7 (1/25) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility
• EFA 14 (4/25) - The Emergency Food Assistance Program (TEFAP) 2025 Income Guidelines
• EFA 15 (4/25) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2025 Income Guidelines

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F

• FDU 113 (3/24) - Civil Rights Annual Training Checklist For CSFP And TEFAP
• FSP 2 (1/21) - Family Stabilization Program Denial Notice - Use Starting May 1, 2022

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G

• GEN 102 (1/22) - Appointment Letter
• GEN 111 (11/20) - Employer Statement Form
• GEN 853 (10/20) - Sworn Statement
• GEN 1179 (5/18) - Complaint of Discrimination
• GEN 1388 (9/15) - Language Accessibility Services Complaint Form
• GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case
• GEN 2101 (3/24) - Non-Work Social Security Number Request Form

I

L

• LIC 613B (6/22) - Personal Rights Children’s Residential Facilities
• LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports

M

• M16-105 (7/02) - EBT Expedited Availability
• M16-215 (7/02) - EBT Availability
• M16-325A (7/02) - EBT Exemption Request
• M16-325B (7/02) - EBT Exemption: Need Additional Facts
• M16-325C (7/02) - EBT Exemption: Deny
• M16-325D (8/08) - EBT Exemption Ended
• M16-701 (8/08) - EBT Adjustment Advice
• M16-505A (8/08) - Designated Alternate Cardholder
• M16-705 (6/23) - EBT Adjustment Denial 
• M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40-107A (4/21) - Time On Aid (no previous NOa issued), Other - Use Starting May 1, 2022
• M40-107B (4/21) - Time On Aid at Redetermination - Use Starting May 1, 2022
• M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022
• M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients - Use Starting May 1, 2022
• M40-107F (4/21) - Extended Beyond 60 Months of Aid - Use Starting May 1, 2022
• M40-107F1 (4/21) - Extender Met After 60th Month - Use Starting May 1, 2022
• M40-107F2 (4/21) - Extender Ended - Use Starting May 1, 2022
• M40-107G (1/22) - 60th Month On Aid, Discontinue - Use Starting May 1, 2022
• M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue
• M40-107J (4/21) - Timed-Out Adult, Partial Approval - Use Starting May 1, 2022
• M40-107J1 (4/21) - Approval After 60 Months on Aid - Use Starting May 1, 2022
• M40-107K (4/21) - Increase Grant due to TOA Adjustment - Use Starting May 1, 2022
• M40-129B (11/09) - Full Payment - Approve
• M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve
• M40-129C (12/90) - Miscellaneous, Deny
• M40-129D2 (12/90) - Procedural Requirements, Deny
• M40-129D3 (12/90) - Procedural Requirements, Deny
• M40-129D4 (9/00) - Procedural Requirements, Deny
• M40-129D5 (11/14) - Failed to Provide Proof of SSN Application, Deny
• M40-129E1 (12/90) - No Emergency, Deny
• M40-129E2 (12/90) - No Emergency, Deny
• M40-129E4 (12/90) - No Emergency, Deny
• M40-129E5 (12/90) - No Emergency, Deny
• M40-129E6 (12/90) - No Emergency, Deny
• M40-181 (9/13) - SAWS 2 Redetermination Of Eligibility
• M40-181C SAR (9/13) - Notice Of Action - Balderas Reminder Notice
• M40-181F (7/22) - No Change at Redetermination
• M40-181G (10/23) - Redetermination Reminder Notice
• M40-195A (8/22) - ICT Notice Of Transfer, Sending
• M40-195B (8/22) - ICT Notice Of Transfer, Receiving
• M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval
• M44-207K (5/20) – Financial Eligibility, Discontinue
• M44-207K1 (5/20) - Minor Parent, Financial Eligibility
• M44-207M (8/20) - Financial Eligibility, Deny
• M44-211L (9/23) - Pregnancy Special Needs, Approve
• M44-211N (9/23) - Pregnancy Special Needs, Change
• M44-211O (9/23) - Discontinue Pregnancy Special Needs Payment for Pregnant Person Only Assistance Unit
• M44-315A (5/20) - $10 Minimum Payment, Change - Use Until April 30, 2022
• M44-315A (8/21) - $10 Minimum Payment, Change - Use Starting May 1, 2022
• M44-316 SAR (4/25) - No Change/Mid-Period Reporting
• M44-316A (9/13) - Notice Of Action - Not Yet Changed
• M44-316B (9/13) - Notice Of Action - Change In Income Over IRT
• M44-316C (8/22) - Notice Of Action - No Change/Mid-Period Report Of Property
• M44-316D SAR (9/13) - Notice Of Action - Change In Income
• M44-340 (2/23) - Underpayment Adjustment, Approval
• M44-350I SAR (9/13) - Notice Of Overpayment
• M44-350K (7/25) – EBT Replacement Denial
• M44-350L (12/18) - Notice Of Overpayment
• M44-350O (11/24) - Notice of Suspected Fraud
• M44-352H (2/23) - Overpayment Adjustment
• M44-352I (11/24) - Notice of Settled Overpayment
• M44-353 (11/24) - Notice Of Overpayment Discharge
• M81-215E (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M81-215F (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M82-812A (6/24) - Start of Cash Aid for Family Reunification Case
• M82-812B (6/24) - End of Cash Aid Following Family Reunification Discontinuance - Child Returned to Home
• M82-812C (11/24) - Family Reunification - End of Cash Aid
• M82-820A (9/21) - No Eligible Person, Deny
• M82-820D (9/23) - No Longer Eligible, Discontinue
• M82-832H (10/20) - Child Does Not Meet Requirements (SB 380)

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N

• NA Back 9 (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412)
• NA IHSS Back L (3/15) - Your Hearing Rights
• NA 200 (12/20) - Notice Of Action - Multipurpose - Include Budget - Use Starting June 1, 2021
• NA 200 (7/21) - Notice Of Action - Multipurpose - Include Budget - Use Starting June 1, 2022
• NA 210 (5/20) - Discontinue, Suspend Financial Eligibility - Use Starting June 1, 2020
• NA 213 (10/21) - Deny - Financial Eligibility
• NA 213A (12/20) – Notice Of Action – Deny – Financial Eligibility - Use Starting June 1, 2021
• NA 213A (7/21) – Notice Of Action – Deny – Financial Eligibility - Use Starting June 1, 2022
• NA 271 (12/20) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid - Use Starting June 1, 2021
• NA 271 (7/21) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid - Use Starting June 1, 2022
• NA 274G (7/19) - Notice Of Action - Continuation Page - Overpayment Computations Occurring On Or After 10/1/2013 To 5/31/2020
• NA 274H (12/20) - Notice Of Action - Continuation Page - Overpayment Computations Between 6/1/2020 and 05/31/2021
• NA 274I (7/21) - Notice Of Action - Continued - Overpayment Amount Owed For Overpayments Occurring Between 6-1-2021 and 5-31-2022
• NA 274J (7/21) - Notice of Action – Continued - Overpayment Amount Owed For Overpayments Occurring On or after 6-1-2022
• NA 281C (7/19) - Notice Of Action - Continuation Page - Underpayment Computations Occurring On Or After 6/1/2020
• NA 281C (12/20) - Notice Of Action Continuation Page - Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2020 and 5-31-2021) – Use Starting June 1, 2021
• NA 281D (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2021 and 5-31-2022)
• NA 281E (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring On Or After 6-1-2022)
• NA 290 (2/14) -Notice of Action - Multipurpose
• NA 300 (7/19) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Test - Use Until May 31, 2021
• NA 300 (10/21) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Tests - Use Starting June 1, 2021
• NA 301 (10/21) - Continuation Page - Applicant Financial Eligibility Test
• NA 320 (10/23) - In-Home Supportive Services (IHSS) Description of Services
• NA 320 LP (10/23) - In-Home Supportive Services (IHSS) Description of Services - (Large Print)
• NA 530 (4/21) - Notice Of Action - 60-Month Time Limit - Use Starting May 1, 2022
• NA 531 (7/19) - Notice Of Action - Continuation Page - 48-Month Time Limit - Use Starting June 1, 2020
• NA 531 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget - Use Starting May 1, 2022
• NA 531 (7/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget - Use Starting June 1, 2022
• NA 532 (12/20) - Notice Of Action - Continuation Page - 48-Month Time Limit Discontinue - Includes Budget - Use Starting June 1, 2021
• NA 532 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit Discontinue - Includes Budget - Use Starting May 1, 2022
• NA 532 (11/21) - Notice Of Action - Continuation Page - 60-Month Time Limit Discontinue - Includes Budget - Use Starting June 1, 2022
• NA 691 (9/23) - Notice Of Denial - Cash Assistance Program For Immigrants (CAPI)
• NA 692 (9/23) - Notice of Change - Cash Assistance Program For Immigrants (CAPI)
• NA 693 (9/22) - Notice of Approval - Cash Assistance Program For Immigrants (CAPI)
• NA 816 (3/14) - Notice Of Action - Sanction Of Other Parent After Failed Compliance Plan
• NA 816A (1/24) - Notice Of Action - Sanction Of Other Parent After Failed Compliance Plan (FR) - Use Starting January 1, 2025
• NA 817 (3/14) - Notice Of Action - Sanction Of Participant After Failed Compliance Plan
• NA 817A (6/24) - Notice Of Action - Disqualification After Failed Compliance (FR) - Use Starting January 1, 2025
• NA 817B (4/24) - Notice Of Action - Sanction Of Participant in Two-Parent AU After Failed Compliance Plan (FR) - Use Starting January 1, 2025
• NA 818 (3/14) - Notice Of Action - Taking You Out Of Welfare To Work
• NA 820 (8/25) - Notice Of Action - Transportation Approval
• NA 821 (8/25) - Notice Of Action - Transportation Discontinuance/Denial
• NA 832 (1/26) - Notice of Action - Child Care Services
• NA 833 (4/20) - Notice of Action - Child Care Services Change
• NA 834 (3/20) - Notice of Action - Child Care Services Denial
• NA 835 (3/20) - Notice of Action - Child Care Services Discontinuance
• NA 840A (10/03) - Notice Of Action - Determination Of Good Cause/No Good Cause
• NA 840B (4/24) - Notice of Action - Welfare-To-Work Plan – Denial (FR) - Use Starting January 1, 2025
• NA 840C (5/24) - Notice Of Action - Welfare to Work Plan in a Two-Parent AU (FR) - Use Starting January 1, 2025
• NA 840D (4/24) - Notice of Action - Welfare To Work Plan Continuance/Discontinuance (FR) - Use Starting January 1, 2025
• NA 841 (3/14) - Notice Of Action - Welfare-To-Work Plan
• NA 844 (4/25) - Notice Of Action - Adequate Progress
• NA 845 (3/14) - Notice Of Action - Sanction and Removal Of The Other Parent's Needs
• NA 845A (5/24) - Notice Of Action -Sanction and Removal Of The Other Parent's Needs (FR) - Use Starting January 1, 2025
• NA 960X SAR (9/13) - Notice Of Action - Stop Aid; Report Not Received
• NA 960Y SAR (10/14) - Notice Of Action - Stop Aid; Report Incomplete
• NA 995 (5/13) - Food Stamp Notice of Denial/Disqualification For The California Food Assistance Program
• NA 1217 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice of Overpayment
• NA 1218 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment
• NA 1230 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Approval
• NA 1231 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Partial Waiver Approval
• NA 1232 (9/23) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Denial
• NA 1239 AR (12/20) - Notice Of Action - Continuation Page - Annual Reporting Budget - Use Starting June 1, 2021
• NA 1239 AR (8/21) - Notice Of Action - Continuation Page - Annual Reporting Budget - Use Starting June 1, 2022
• NA 1239 SAR (12/20) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget - Use Starting June 1, 2021
• NA 1239 SAR (8/21) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget - Use Starting June 1, 2022
• NA 1240 (4/13) - Notice of Action - Food Stamp Overissuance & Dormant EBT Account
• NA 1254 (9/25) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation
• NA 1254 LP (10/25) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation (Large Print, 18pt Font)
• NA 1263 (8/11) - Notice of Action - Overissuance Budget Worksheet
• NA 1263 (10/25) – CalFresh/California Food Assistance Program (CFAP) - State CalFresh Notice Of Action (Continued) - Use Starting October 1, 2025
• NA 1267 (4/13) - CalFresh Informing Notice Of Receiving Intercounty Transfer
• NA 1268 (4/13) - CalFresh Informing Notice Of Sending Intercounty Transfer
• NA 1273 (7/13) - Electronic Notification Agreement
• NA 1274 (7/13) - Electronic Notification Notice
• NA 1275 (7/13) - Electronic Notification Cancellation Notice
• NA 1276 (1/15) - Notice Of Action - Welfare-to-Work 24-Month Time Clock Limit Notice
• NA 1282 (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay
• NA 1282L (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay

P

• PUB 13 (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California
• PUB 13L (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California (Large Print)
• PUB 104 (12/06) - In-Home Supportive Services Individual Provider Benefits and Services Information
• PUB 190 (8/06) - How To Hire And Supervise Your In-Home Supportive Services (IHSS) Provider (Western Armenian)
• PUB 203 (1/04) - In-Home Supportive Services - Guide to Workers’ Compensation Benefits for Individual Providers
• PUB 373 (Print 8 1/2 X 11) (5/07) - Important Food Stamp Information For Noncitizens
• PUB 373 (Print 11 X 17) (5/07) - Important Food Stamp Information For Noncitizens
• PUB 388 (2/24) - California Electronic Benefit Transfer (EBT) Card
• PUB 389 (2/24) - California Electronic Benefit Transfer (EBT) Card - How To Use Your EBT Card To Make A Purchase
• PUB 390 (2/06) - California Electronic Benefit Transfer (EBT) Card - How To Use Your EBT Card To Buy Food. This is a VERY LARGE file. Please download it to your computer prior to opening it by using the instructions from item #2 on this page: Tips for Using Adobe PDF Files
• PUB 470 (4/21) - Your Rights Under Adult Protective Services
• PUB 484 (7/15) - Keep More Of Your Money - Poster
• PUB 520 (11/21) - Great News! Based On Your Medi-Cal Eligibility Your Household May Be Eligible For CalFresh Food Benefits
• PUB 521 (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Adults
• PUB 521L (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Adults (Large Print)
• PUB 522 (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Minor Children
• PUB 522L (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Minor Children (Large Print)
• PUB 524 (2/23) - Protect Your Benefits – Beware Of Skims And Scams
• PUB 525 (11/23) - Protect Yourself From Electronic Theft By Downloading The ebtEDGE Mobile Application Today
• PUB 526 (12/23) - You May Be Eligible For Retroactive CalFresh Benefit Theft Replacements
• PUB 531 (12/24) - New EBT CHIP/TAP Card - Tap or Insert to Avoid the Trap
• PUB 531A (12/24) - New EBT CHIP/TAP Card - Tap or Insert to Avoid the Trap (Brief Version)

Q

R

• RAD 03 (2/21) – Suspected Unemployment Insurance Fraud And identity Theft Information

S

• SAR 2 (6/19) - Reporting Changes For Cash Aid And CalFresh
• SAR 2LP (6/19) - Reporting Changes For Cash Aid and CalFresh (20pt Font)
• SAR 3 (2/15) - Mid-Period Status Report For Cash Aid and CalFresh
• SAR 7 (12/14) - Eligibility Status Report – For Cash Aid and CalFresh
• SAR 7 (12/23) - 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 – For Cash Aid and CalFresh
• SAR 7A (12/23) - How To Fill Out Your SAR 7 Eligibility Status Report
• SAR 7AB (12/23) - How To Fill Out Your SAR 7 Eligibility Status Report - Blank
• SAR 7B (12/23) - SAR 7 Eligibility Status Report
• SAR 7 DA (12/23) - Domestic Abuse Addendum to the SAR 7
• 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
• SAR 90 (1/14) - Reminder Letter
• 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
• 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 111 (8/24) – Coversheet Cash Assistance Program for Immigrants (CAPI) Redetermination Form
• SOC 295 (9/18) - Application For In-Home Supportive Services (14pt Font)
• SOC 295L (9/18) – Application For In-Home Supportive Services (18pt Font)
• SOC 310 (1/03) - Statement Of Facts For In-Home Supportive Services
• SOC 321 (11/99) - Request For Order And Consent - Paramedical Services
• SOC 332 (9/09) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist)
• SOC 332L (1/19) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist)
• SOC 341 (2/24) - Report Of Suspected Dependent Adult/Elder Abuse
• SOC 341A (2/24) - Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders
• 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 450 (2/23) - Voluntary Services Certification
• SOC 453 (8/22) - Cash Assistance Program For Immigrants (CAPI) Statement Of Household Expenses And Contributions
• SOC 455 (1/99) - Authorization for State Reimbursement of Interim Assistance
• SOC 600 (4/24) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider CalSavers Payroll Deduction Authorization / Change / Cancellation Form
• SOC 804 (2/20) - Statement Of Facts For Determining Continuing Eligibility For The Cash Assistance Program For Immigrants (CAPI)
• SOC 809 (10/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Statement
• SOC 814 (12/20) - Statement Of Facts Cash Assistance Program For Immigrants (CAPI)
• SOC 821 (3/06) - Assessment Of Need For Protective Supervision For In-Home Supportive Services Program
• SOC 825 (6/06) - Protective Supervision 24-Hours-A-Day Coverage Plan
• SOC 829 (10/18) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider Direct Deposit Enrollment/Change/Cancellation Form
• SOC 830 (9/22) - Request for Conditional CAPI After Naturlization Pending SSI/SSP Eligiblity Determination
• SOC 831 (10/18) - IHSS Provider Letter
• SOC 838 (10/12) - In-Home Supportive Services (IHSS) Recipient Request For Assignment Of Authorized Hours To Providers
• SOC 839 (8/25) - In-Home Supportive Services (IHSS) Designation Of Authorized Representative
• SOC 839 LP (9/25) - In-Home Supportive Services (IHSS) Designation Of Authorized Representative (Large Print)
• SOC 839A (8/25) - In-Home Supportive Services (IHSS) Designation of Signatory for TPRD
• SOC 839A LP (9/25) - In-Home Supportive Services (IHSS) Designation of Signatory for TPRD (Large Print)
• SOC 839B (6/23) - In-Home Supportive Services (IHSS) Cancellation of Authorized Representative-TPRD Signatory
• SOC 839B LP (8/25) - In-Home Supportive Services (IHSS) Cancellation of Authorized Representative-TPRD Signatory (Large Print)
• SOC 840 (10/12) - In-Home Supportive Services (IHSS) Program Provider Or Recipient Change Of Address And/Or Telephone
• SOC 843 (2/26) - Request For Conditional CAPI Pending The Disposal Of Excess Non-Liquid Resources
• 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 (9/22) – In-House 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 856L (7/19) - 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 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 (2/26) - In-Home Supportive Services (IHSS) Program Individualized Back-up Plan and Risk Assessment
• SOC 864 LP (12/25) - In-Home Supportive Services (IHSS) Program Individualized Back-up Plan and Risk Assessment (Large Print)
• SOC 865 (7/12) - IHSS Request For Applicant Provider Reference
• SOC 865L (10/18) - 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 (Large Print)
• SOC 874 (10/16) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification
• 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
• SOC 875L (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement
• SOC 876 (4/23) - 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 887A (12/20) - Cash Assistance Program For Immigrants (CAPI) Nonmedical Out-Of-Home Care (NMOHC) Payment Standard Eligibility Determination - Retroactive Certification of NMOHC Payment Standard Eligibility
• 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 (3/21) - In-Home Supportive Services (IHSS) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours
• SOC 2271A (11/15) - In-Home Supportive Services (IHSS) Program Recipient Notice Of 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 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-Home Supportive Services Program Notice To Applicant Of Application Confirmation Number
• SOC 2301 (4/17) - In-Home Supportive Services (IHSS) Or Waiver Personal Care Services (WPCS) Recipient Confirmation Of Enrollment In Electronic Timesheet Service Or Telephone Timesheet System
• SOC 2302 (5/19) - In-Home Supportive Services (IHSS) Program Provider Paid Sick Leave
• 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 Workweek Limits For Extraordinary Circumstances (Exemption 2)
• SOC 2310A (5/19) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Ineligibility For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2)
• 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 Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In Eligibility
• SOC 2312A (3/20) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In 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 (8/25) - In-Home Supportive Services (IHSS) Recipient’s Responsibility To Stop Sexual Harassment In The Workplace
• SOC 2326 LP (10/25) - In-Home Supportive Services (IHSS) Recipient’s Responsibility To Stop Sexual Harassment In The Workplace (Large Print)
• SOC 2327 (8/25) - In-Home Supportive Services (IHSS) Provider’s Right To File A Sexual Harassment Complaint
• SOC 2327 LP (10/25) - In-Home Supportive Services (IHSS) Provider’s Right To File A Sexual Harassment Complaint (Large Print)
• SSGP 45 (5/24) - The State Supplemental Grant Program (SSGP)
• SSP 14 (9/10) - Authorization For Reimbursement Of Interim Assistance Initial Claim Or Posteligibility Case
• SSP 18 (3/24) - Notice Of Action And Right To Request A State Hearing On Interim Assistance

T

• 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 EBT
• TEMP 2250 (6/24) - 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 2252 (12/20) - State Law Changes The CalWORKs Earned Income Disregard - Use Starting June 1, 2021
• TEMP 2252 (3/22) - State Law Changes The CalWORKs Earned Income Disregard - Use Starting June 1, 2022
• TEMP 2316 (5/22) - Sick Leave Yearly Notification
• TEMP 3005 (12/14) - Changes For People With A Prior Felony Drug Conviction
• TEMP 3011 (1/24) – Child and Family Team (CFT) & Child and Adolescent Needs and Strengths Tool (CANS) - For Parents
• TEMP 3012 (1/24) – Child and Family Team CFT and CANS - For Youth
• TEMP 3013 (1/24) – Child and Family Team (CFT) & Child and Adolescent Needs and Strengths Tool (CANS) - For Professionals
• TEMP 3014 - (2/20) Treasury Offset Program (TOP) Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3015 - (2/20) Franchise Tax Board (FTB) Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3015A (2/20) - Franchise Tax Board (FTB) Annual Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3017 - (2/20) - Treasury Offset Program Notification Of Offset
• TEMP 3022 - (8/21) - Important Information For CalWORKs Families -State Law Increases The CalWORKs Time Limit To 60 Months
• TEMP CF 1468 (2/15) - CalFresh Notice Of Change
• TEMP CW 2225 (10/20) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Disregard/Pass-Through Rules
• TEMP NA 1238 (4/23) – CalFresh Notice Of Action EBT Account Adjustment
• TEMP WI 10072 (8/13) - EBT Replacement Approval
• TEMP WI 10072A (8/13) - EBT Replacement Review
• TILP 1 (1/23) - Transitional Independent Living Plan & Agreement
• TM44-315K (7/19) - Law Change To MAP Levels
• TM44-315M (7/22) - Law Change To MAP Levels
• TM44-315N (7/23) - Law Change To MAP Levels
• TM44-315N (7/23) - Law Change To MAP Levels
• TM44-315O (7/24) - Law Change to MAP Levels
• TM82-832 (12/14) - Basic Approval
• 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

W

• WI 10072A (10/23) - EBT Replacement Approval
• WI 10072B (10/23) - 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 2 (6/24) - Welfare To Work Plan Activity Assignment
• WTW 4A (4/24) - Notice to Other Parent - Use Starting January 1, 2025
• WTW 5 (5/23) - Welfare-To-Work Program Notice
• WTW 10 (7/99) - Request for Welfare to Work Third Party Assessment
• WTW 15 (9/13) - Simplified CalFresh Program Unpaid Work Experience (WEX) And Unpaid Community Service Hours Worksheet
• WTW 16A (3/22) - Grant-Based OJT Income Examples For Region 1 - Use Starting June 1, 2022
• WTW 16B (3/22) - Grant-Based OJT Income Examples For Region 2 - Use Starting June 1, 2022
• WTW 17 (12/15) - Waiver Of CalWORKs Learning Disabilities Screening And/Or Evaluation
• 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 34 (1/24) - Welfare To Work Family Reunification Plan - Use Starting January 1, 2025
• WTW 37 (7/09) - Permission To Release Domestic Abuse Information When Moving To Another County
• WTW 47 (3/15) - Online CalWORKs Appraisal Tool Rights And Privacy
• WTW 51 (1/21) - Welfare To Work Noncompliance Checklist Tool - Use Starting May 1, 2022
• WTW 100 (10/25) - Good Cause/Exemption Letter
• WTW 112 (3/21) - Care Of A Household Member Verification
• WTW 246 (5/25) - Employment Workshop & Job Search Notice
• WTW 2490 (11/20) - Non-Receipt Of WTW Attendance/Progress Report
• WTW 6010 (5/25) – WTW Appointment Letter