Spanish

Translated Spanish Forms

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A

• AAP 1 (11/22) - Request For Adoption Assistance Program Benefit
• AAP 3 (6/22) - Reassessment Information - Adoption Assistance Program
• AAP 5 (9/18) - Adoptions Assistance Program Independent Adoptions Program
• AAP 6 (11/22) - Adoption Assistance Program Negotiated Benefit Amount and Approval
• AAP 7 (12/17) - Adoptions Assistance Program Statement Of Acknowledgement
• AAP 8 (9/18) - Adoption Assistance Program Nonrecurring Adoption Expenses Agreement
• AAP 9A (5/21) - Adoption Assistance Program (AAP)Level Of Care Rate Determination Protocol Matrix
• AAP 10 (10/21) - Prospective Or Adoptive Parent(s) Level Of Care (LOC) Reporting Tool
• ABCDM 228 (3/24) - Applicant's Authorization For Release Of Information
• ABCD 239.7A (8/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• 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 1A (4/22) - Parental Consent To Adoption (In Or Out-Of-California)
• AD 1F (4/15) - Parental Consent To Adoption Outside California In Armed Forces - Independent Adoption Program
• AD 2A/2B (5/11) - Stepparent Adoption (Consent to Adoption by a Parent in or outside of California Giving Custody to Husband or Wife or Domestic Partner of Other Parent)
• AD 2D (3/08) - Stepparent Adoption Consent To Adoption By Parent Outside California In Armed Forces Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent
• AD 9 (11/07) - Independent Adoption Questionnaire
• AD 10 (9/03) - Request for Reference
• AD 20 (4/15) - Refusal To Give Parental Consent To Adoption - Independent Adoptions Program
• AD 20B (5/15) - Refusal To Give Consent To Adoption - Alleged Natural Father, Independent Adoption Program
• AD 22 (7/02) - Health Facility Minor Release Report
• AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care
• AD 67 (7/24) - Information About The Biological Mother/Legal Parent - Agency And Independent Adoptions Program
• AD 67A (7/24) - Information About The Biological Father/Legal Parent - Agency And Independent Adoptions Program
• AD 90 (6/13) - Supporting Information For Issuance Of California Department Of Social Services Acknowledgement And Confirmation Of Receipt Of Child Freeing Documents
• AD 100 (9/22) - Authorization For Use And/Or Disclosure Of Health Information Independent Adoption Program
• AD 100A (3/08) - Authorization For Use And/Or Disclosure Of Health Information Agency Adoption Program
• AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In or Out-of-California)
• AD 501 (4/24) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father In California)
• AD 501A (4/24) - Relinquishment Out-of-State (Birth Mother/Biological Father/Presumed Father)
• AD 504 (5/15) - Relinquishment – Out of State In Armed Forces (Birth Mother/Biological Father/Presumed Father)
• AD 508 (7/13) - Rescission Request/Rescission Of Relinquishment
• AD 512 (12/24) - Psychosocial And Medical History Of Child
• AD 512 NMD (12/24) - Psychosocial And Medical History Of Non-Minor Dependent
• AD 513 NMD (8/22) - Non-Minor Dependent Adoption Mutual Disclosure Agreement
• AD 558 (12/24) - Notice Of Placement (To Be Sent Within 15 Days of Placement)
• AD 583 ENG/SP (5/15) - Relinquishment – In Or Out Of County - Presumed Father Denies He Is The Birth Father
• AD 584 ENG/SP (8/12) - Relinquishment Out of State - Presumed Father Denies He is the Birth Father
• AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California)
• AD 590 (4/15) - Waiver Of Right To Further Notice Of Adoption Planning (Alleged Natural Father In Or Out Of California) - Agency And Independent Adoptions Program
• AD 590A (9/24) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Parent In Or Out Of California - Agency And Independent Adoptions Program
• AD 591 (12/14) - Relinquishment Out-of-State (Alleged Natural Father)
• AD 593 (5/22) - Relinquishment – Out of State in Armed Forces (Alleged Natural Parent)
• AD 594 (5/24) - Alleged Father's Consent To Adoption (In Or Out Of California) - Independent Adoptions Program
• AD 842 (3/17) - Alleged Father's Consent To Adoption (Outside California In The Armed Forces)
• AD 859 (8/15) - Parental Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program
• AD 860 (8/15) - Presumed Father's Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program
• AD 861 (8/15) - Consent To Adoption Of Indian Child By Alleged Father (In Or Out Of California) - Independent Adoption Program
• AD 862 (3/12) - Relinquishment Of An Indian Child Out-Of-State (Alleged Natural Father)
• AD 863 (9/12) - Relinquishment Of Indian Child Out of State - Birth Mother/Presumed Father
• AD 864 (3/08) - Relinquishment Of An Indian Child In Or Out-Of-County - Birth Mother/Presumed Father In California
• AD 866 (10/14) - Relinquishment Of An Indian Child In Or Out-of-County - Presumed Father Denies He Is The Birth Father In California
• AD 867 (3/08) - Relinquishment of an Indian Child - Out-of-State - Presumed Father Denies He is the Birth Father
• AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California
• AD 880 (1/21) – Declaration Of Birth Parent - Agency And Independent Adoptions Program
• AD 885 (3/14) - Mother Or A Biological/Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian
• 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
• AD 885C (2/15) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian
• AD 885D (11/21) - Statement of Understanding - Alleged Parent of a Child Who is Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal Guardian
• AD 887 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The Child To The Petitioner(s)
• AD 887A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s)
• AD 887B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father
• AD 899 (3/08) - Statement of Understanding - Mother or a Presumed Father of the INDIAN Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or a Ward of a Legal Guardian
• AD 899A (11/21) - Statement of Understanding - Mother or a Presumed Father of an Indian Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 899C (3/06) - Statement Of Understanding - Alleged Natural Father of the INDIAN Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 899D (11/21) - Statement Of Understanding - Alleged Parent of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 900 (8/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The INDIAN Child To The Petitioner(s)
• AD 900A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The INDIAN Child To The Petitioner(s)
• AD 900B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father Of An INDIAN Child
• AD 902 (2/22) - Consent For Arranging Contact
• AD 904A (2/24) - Waiver Of Rights To Confidentiality For Siblings
• AD 904B (9/20) - Waiver Of Rights To Confidentiality For Siblings Under The Age Of 18
• AD 907 (5/24) - Adoptive Placement Agreement
• AD 907A (3/23) - Adoptive Placement Agreement for Non-Minor Dependent Adoption
• AD 908 (5/22) - Adoptions Information Act Statement
• AD 918 (11/03) - Family Assessment Questionnaire II
• AD 924 (6/22) - Independent Adoption Placement Agreement - Independent Adoptions Program
• AD 925 (11/23) - Independent Adoption Placement Agreement - Indian Child - Independent Adoptions Program
• AD 926 (1/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Child With The Prospective Adoptive Parent(s)
• AD 927 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Indian Child With The Prospective Adoptive Parent(s)
• AD 928 (7/02) - Revocation Of Consent Independent Adoption Program
• AD 929 (9/18) - Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program
• AD 929A (4/21) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program
• AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment
• AD 933 (12/20) - Intercountry Readoption Acknowledgment
• AD 4317 (3/20) - Revocation Of Relinquishment
• AD 4310 (8/07) - Adoption Programs Notice Required By Information Practices Act
• AD 4317 (3/20) - Revocation Of Relinquishment
• AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement
• AD 4324 (5/24) - Adoption Questionnaire I This is a large PDF file. Tips for Using Adobe PDF Files
• AD 4328 (3/06) - Authorization For Release Of Personal Items
• AD 4336 (4/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (Outside California In Armed Forces) - Independent Adoption Program
• ADM 36 (6/99) - Medical Report Regarding Child To Be Adopted
• ADSA 1 (3/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits
• ADSA 1A (5/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits
• ADSA 1AL (11/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits - Large Print
• ADSA 1B (6/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits
• ADSA 1BL (7/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits
• ADSA 1L (5/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits)
• ADSA 2 (10/21) – Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program 
• ADSA 2L (12/21) – Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program - Large Print
• ADSA 3 (10/21) - Assistance Dog Special Allowance (ADSA) Enclosure
• ADSA 3L (11/21) - Assistance Dog Special Allowance (ADSA) Enclosure - Large Print
• AR 2 (11/13) - Reporting Changes For CalWORKs And CalFresh
• AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh
• AR 3 (2/15) - Mid-Year Status Report For CalWORKs and CalFresh
• ARC 1 (4/22) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program
• ARC 1A (11/16) Rights, Responsibilities, And Other Important Information
• ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved

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C

• CAS 854 (4/15) - Agency Adoption Fee - Reduction Request
• CCD 21 (9/24) - Parent Plan For Seeking Employment (PPSE)
• CCD 26 (9/23) – Confidential Application for Child Development Services and Certification of Eligibility
• CCD 26A (10/24) – Instructions for Completing Form CCD 26: Confidential Application for Child Development Services and Certification of Eligibility
• CCD 27 (8/22) - Statement Of Parental Incapacitation
• CCD 35 (8/22) - Educational Programs or Vocational Training Verification for Parent or Caretaker Attending Educational Programs or Receiving Vocational Training
• CCD 7617 (10/24) - Notice Of Action
• CCP 1 (3/15) - Declaration of Exemption from Trustline Registration and Health and Safety Self-Certification
• CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers)
• CCP 6 (8/99) - Health And Safety Checklist
• CCP 7 (5/24) - CalWORKs Child Care Request Form And Child Care Payment Rules
• CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form
• CCP 2145 (7/23) - CalWORKs Child Care Reimbursement Report
• CD 9600 (12/99) - Confidential Application For Child Development Services And Certification Of Eligibility
• CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read
• CF 10 (12/13) - Dependent Care Cost Affidavit
• CF 11 (8/23) - Notice To All CalFresh Recipients - Use Starting October 1, 2023 
• CF 11 (9/24) - Notice To All CalFresh Recipients - Use Starting October 1, 2024
• CF 12 (1/25) - Notice to CalFresh Recipients
• CF 18 ENG/SP (2/14) - 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 Supplement Affidavit/Authorization
• CF 304A (9/20) - Important Information About Your CalFresh Benefits - CalFresh Water Pilot
• CF 304B (9/20) -Notice Of Approval For The CalFresh Water Pilot
• CF 304C (9/20) -Notice Of Discontinuance For The CalFresh Water Pilot
• CF 304D (10/22) - Notice Of CalFresh Water Pilot Extension
• CF 304E (7/23) - Notice Of CalFresh Water Pilot Extension Second Extension 
• CF 304F (10/24) - Notice of CalFresh Water Pilot Extension
• CF 377.1 (8/24) - Notice Of Approval For CalFresh Benefits
• CF 377.1A (8/24) - Notice Of Denial Or Pending Status
• CF 377.1A LP (8/21) - Notice Of Denial Or Pending Status - Large Print
• CF 377.10 (2/24) - CalFresh Notice Of Denial/Disqualification For Failure To Meet General CalFresh Work Rules
• CF 377.11 (11/23) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement
• CF 377.11A (11/23) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11B (9/23) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11C (1/20) - CalFresh Informational Notice - CalFresh Time Limit For Able-Bodied Adults without Dependents (ABAWDs)
• CF 377.11E (12/23) – 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 (10/20) - 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 377.7B1 (10/17) - CalFresh Repayment Notice For Inadvertent Household Errors Only Final Notice
• 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 377.11D (1/20) – CalFresh Discretionary Exemption For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 378A (11/24) - Minimum Nutrition Benefit Pilot Program Approval Notice
• CF 378B (11/24) - Minimum Nutrition Benefit Pilot Program Discontinuance Notice
• 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 (7/24) - CalFresh Notice Of Restoration Approval
• CF 389 (7/24) - Notice Of Denial Of Restoration
• CF 390 (5/19) – Notice of Approval/Denial For Disaster CalFresh
• 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 502 (2/23) - Notice To All CalFresh Recipients - End Of CalFresh Emergency Allotments
• CF 886 (11/23) - CalFresh Notice Of Work Rules
• CF 889 (12/23) - CalFresh Restaurant Meals Program Approval/Termination Notice of Action
• 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
• CRF 01 (10/20) - Coronavirus Relief Fund (CRF) Certification Of Eligibility
• CL 1 (4/99) - Cal-Learn Registration Program Information Orientation Appointment
• CL 2 (4/99) - Cal-Learn PROGRAM REQUIREMENTS
• CL 3 (4/99) - Cal-Learn Notice Of A Participation Problem
• CL 4 (4/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant
• CL 8 (3/99) - Cal-Learn Notice Of Report Card Submittal Schedule
• CL 9 (3/99) - Cal-Learn Notice Of Good Cause Determination
• CL 10 (4/99) - Cal-Learn Notice Of Exemption/Deferral
• CL 11 (4/99) - 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 2.1 N A (8/04) - Notice And Agreement For Child, Spousal And Medical Support
• CW 2.1Q (10/16) - Support Questionnaire
• CW 4 (6/02) - Immediate Need Payment Request
• CW 5 (7/01) - Veterans Benefits Verification and Referral
• CW 8 (11/14) - Statement of Facts For An Additional Person
• CW 8A (12/14) - Statement Of Facts To Add A Child Under Age 16
• CW 10 (7/01) - Notice of Withdrawn Application
• CW 13 (9/02) - Caretaker Relative Agreement
• CW 23 (3/00) - Senior Parent - Statement Of Facts
• CW 25 (7/01) - Supplemental Statement Of Facts - Minor Parent
• CW 25A (2/13) - Payee Agreement For Minor Parent
• CW 30 (12/23) – CalWORKs Budget Worksheet - Use Starting June 1, 2020
• CW 31 SAR (4/13) - Receipt For Documents
• CW 42 (9/23) - Statement of Facts - Homeless Assistance
• CW 43 (3/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant
• CW 51 (10/11) - Child Support - Good Cause Claim For Noncooperation
• CW 52 (7/18) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Assistance Unit And Child Support Rules
• CW 52 (10/20) – California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Instead Of Cash Grant Option
• CW 60 (5/01) - Release Of Information - Financial Institution
• CW 61 (7/01) - Authorization to Release Medical Information
• CW 61A (6/01) - Physical Capacities
• CW 61B (6/01) - Mental Capacities
• CW 63 (11/20) - Request For Income And/Or Resource Verification
• CW 71 (3/00) - Statement Of Cash Aid Mother And Unrelated Adult Male (UAM)
• CW 74 (9/19) - Permanent Housing Search Document
• CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs
• CW 81 (4/10) - Lien Agreement
• CW 82 (3/00) - Important Information About This Agreement
• CW 86 (10/21) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• CW 87 (6/02) - Reinforming Letter/Add a Person(s) Program
• CW 88 (6/11) - Diversion Services Agreement CalWORKs Program
• CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services
• CW 89 (2/03) - Application Withdrawl Request
• CW 101 (7/17) - CalWORKs Immunization Rules
• CW 103 (11/09) - Multilingual - Transitional Medi-Cal
• 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 2103 (6/16) - Reminder For Teens Turning 18 Years Old
• CW 2166 (12/20) - Multilingual Work Really Pays! Here's How - Use Starting June 1, 2020
• CW 2166 (11/21) - Multilingual Work Really Pays! Here's How - Use Starting June 1, 2022
• CW 2184 (8/16) - CalWORKS 48-month Time Limit
• CW 2184 (1/24) - CalWORKs 60-Month Time Limit - Use Starting October 1, 2024
• CW 2186A (4/21) - CalWORKs Exemption Request Form - Use Starting May 1, 2022
• CW 2186A (1/24) - CalWORKs Exemption Request Form - Use Starting October 1, 2024
• CW 2186B (4/21) - CalWORKs Exemption Determination - Use Starting May 1, 2022
• CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit - Use Until April 30, 2022
• CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit - Use Starting May 1, 2022
• CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program
• 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)
• CW2190A (4/16) - CalWORKs 48-Month Time Limit Extender Request Form
• CW2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form
• 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 2200LP (6/19) - Request For Verification (20pt Font)
• CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form
• CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit
• CW 2205 (10/12) - New Rules For CalWORKs Welfare-To-Work Activities
• CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock
• CW 2209 (12/14) - Immunization Good Cause Request Form
• 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 2217 (1/15) - CalWORKs Request For Voluntary Repayment
• 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 
• CW 2219 (5/16) Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child)
• CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs
• CW 2224 (2/20) - CalWORKs Home Visiting Initiative (HVI)

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D

• 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 For An Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IVP
• DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV) - Large Print
• DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV)Only, Final Notice
• DFA 377.7G (5/02) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only
• DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services
• DPA 19 (6/22) - Appointment Of Authorized Representative
• DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing
• DPA 421 (7/99) - Notification Of Open Record And Waiver Of Time
• DPA 436B (8/18) - County Information Letter

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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

• FC 2 (3/22) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC)
• FC 2 NM (5/22) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC)
• FC 1637 (5/14) - 90-Day Transition Plan
• FCCH - Pre-Orientation Registration Information: Wait!
• FDU 113 (3/24) - Civil Rights Annual Training Checklist For CSFP And TEFAP
• FS 31 ENG/SP (2/09) - Notice To All Food Stamp Recipients - Important-Please Read - Things You Need To Know
• FSP 1 (8/14) - Family Stabilization Program Evaluation Request
• FSP 2 (1/21) - Family Stabilization Program Denial Notice - Use Starting May 1, 2022
• FSP 3 (8/14)Family Stabilization Program Notice of Change in Program Status

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G

• GEN 100 (11/20) - Examples Of Verification
• GEN 102 (1/22) - Appointment Letter
• GEN 107 (8/20) - Message From The County
• GEN 111 (11/20) - Employer Statement Form
• GEN 788 (3/22) - Request To Stop My Benefits
• GEN 788LP (3/22) - Request To Stop My Benefits - Large Print
• 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

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H

• HCS 100 (7/23) - Application For Home Care Aide Registration or Renewal

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I

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K

• KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds
• KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (KinGAP) Program
• KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents
• KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement
• KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form

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L

• LIC 01A (6/23) - Resource Family Application
• LIC 01C (7/16) - Resource Family Application-Confidential
• LIC 03 (7/23) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
• LIC 05A (8/21) - Resource Family Approval Certificate
• LIC 08 (2/24) - Intensive Services Foster Care Unit (ISFC) Written Assessment of Risk and Compatibility
• LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP)
• LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes
• LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application
• LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home
• LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA
• LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA
• LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status
• LIC 192 (7/03) - Notiification Of Initial Application Denial
• LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities
• LIC 198B (9/23) - Out-Of-State Child Abuse/Neglect Report Request
• LIC 200 (2/24) - Application For A Community Care Facility or Residential Care Facility For The Elderly License
• LIC 200A (1/25) - Application for a Child Care Center License
• LIC 215 (7/04) - Applicant Information - Facility License
• LIC 279 (2/09) - Application For A Family Child Care Home License
• LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes
• LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License
• LIC 281A (1/07) - License Application And Instructions For Child Care Centers
• LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency
• LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program
• LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home
• LIC 283 (4/10) - Foster Family Home Application
• LIC 283A (12/07) - Foster Family Home Application Instructions
• LIC 300A (10/23) - Removal Confirmation - Exemption Needed
• LIC 301E (10/22) - Reference Request - Exemption
• LIC 308 (11/02) - Designation of Facility Responsibility
• LIC 309 (6/01) - Administrative Organization
• LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children
• LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home
• LIC 401 (3/01) - Monthly Operating Statement
• LIC 401A (3/99) - Supplemental Financial Information
• LIC 402 (8/04) - Surety Bond
• LIC 403 (7/11) - Balance General
• LIC 403A (9/11) - Balance Sheet Supplemental Schedule
• LIC 404 (7/99) - Financial Information Release And Verification
• LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources
• LIC 420 (4/99) - Budget Information
• LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility)
• LIC 421BG (5/19) - Civil Penalty Assessment – Caregiver Background Check
• LIC 421CC (6/22) - Civil Penalty Assessment – Child Care
• LIC 421D (CC) (8/22) - Civil Penalty Assessment – Death/Serious Injury/Physical Abuse (Child Care)
• LIC 421FC (7/17) - Civil Penalty Assessment – Failure To Correct And Repeat Violations
• LIC 421IM (7/17) - Civil Penalty Assessment – Immediate $500 And Repeat Violations
• LIC 500 (11/03) - Personnel Report
• LIC 501 (3/99) - CCL/Personnel Record
• LIC 503 (3/99) - Health Screening Report - Facility Personnel
• LIC 508B (3/11) - Criminal Record Statement - Long-Term Ombudsman Program
• LIC 508D (10/23) - Out-Of-State Disclosure And Criminal Record Statement
• LIC 508 O-O-S (9/23) - Out-Of-State Disclosure
• LIC 601 (8/08) - Identification And Emergency Information
• LIC 602 (7/22) - Physician's Report For Community Care Facilities
• LIC 603 (6/22) - Preplacement Appraisal Information
• LIC 605A (7/22) - Release Of Client/Resident Medical Information
• LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers
• LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes
• LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes)
• LIC 610D (12/21) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities
• LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly
• LIC 613 (12/02) - Personal Rights Adult Residentail Care Facilities
• LIC 613A (8/08) - Personal Rights - Child Care Centers
• LIC 613B (6/22) - Personal Rights Children’s Residential Facilities
• LIC 613C (1/19) - Personal Rights Residential Care Facilities for The Elderly
• LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly
• LIC 621 (4/99) - Client/Resident Personal Property And Valuables
• LIC 622 (9/19) - Centrally Stored Medication and Destruction Record
• LIC 623 (5/01) - Group Planned Activities
• LIC 624 (4/99) - Unusual Incident/Injury Report
• LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home
• LIC 624-LE (4/17) - Law Enforcement Contact Report
• LIC 625 (10/24) – Appraisal/Needs and Services Plan
• LIC 627 (9/08) - Consent for Medical Treatment - Child Care Centers Or Family Child Care Homes
• LIC 627A (9/08) - Consent To A Medical Examination
• LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities
• LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities
• LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes
• LIC 701 (8/08) - Physician's Report - Child Care Centers
• LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report
• LIC 855 (9/00) - Declaration
• LIC 861 (1/03) - Prelicensing In-Home Interview
• LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights
• LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights
• LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion)
• LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement)
• LIC 995D (5/03) - Family Child Care Home Explanation Of Exclusions And Reinstatement
• LIC 995E (10/09) - Caregiver Background Check Process
• LIC 995F (10/09) - Caregiver Background Check Information
• LIC 999 (3/99) - Facility Sketch Floor Plan/Yard Plan
• LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home
• LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License
• LIC 9040 (10/05) - Child Care Facility Roster
• LIC 9052 (1/22) - Notice Employee Rights
• LIC 9054 (3/99) - Local Fire Inspection Authority Information
• LIC 9058 (3/22) - Applicant/Licensee Rights
• LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse
• LIC 9111 (12/99) - Noncompliance Conference Summary
• LIC 9121 (7/21) - Facility Visit Checklist Family Child Care
• LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC)
• LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form
• LIC 9150 (8/14) - Parent Notification - Additional Children In Care
• LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home
• LIC 9158 (7/22) - Telecommunications Device Notification
• LIC 9163 (1/25) - Request Live Scan Service - Community Care Licensing
• LIC 9166 (2/01) - Consent/Verification for Nebulizer Care
• LIC 9182 (11/23) - Criminal Background Clearance Transfer Request
• LIC 9188 (11/23) - Criminal Record Exemption Transfer Request
• LIC 9211 (9/21) - Request For Inactive Child Care License Status
• LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care
• LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative
• LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home
• LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart
• LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities
• LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports
• LIC 9225 (4/10) - Pre-Placement Questionnaire
• LIC 9227 (8/20) - Individual Infant Sleeping Plan
• LIC 9281 (01/22)- Small Family Home Risk Assessment

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M

• M16_105 (7/02) - EBT Dormant Account
• M16-120A (6/11) - EBT Dormant Account
• M16-120B (6/11) - EBT Dormant Account: Suspend
• M16_120C (7/02) - EBT Dormant Account - Reactivate
• M16_215 (7/02) - EBT Availability
• M16_325A (7/02) - EBT Exemption Request
• M16_325B (7/02) - EBT Incomplete Document
• M16_325C (7/02) - EBT Exemption Deny
• M16-325D (8/08) - EBT Exemption Ended
• M16-325E (8/08) - Direct Deposit Cancellation
• M16_505A (7/02) - Designated Alternate Cardholder
• M16_505B (7/02) - Designated Alternate Cardholder - Need Additional Facts
• M16_505D (7/02) - Designated Cardholder - Deny
• M16 701 (8/08) - EBT Adjustment Advice
• M16-705 (6/23) - EBT Adjustment Denial 
• M20 003 (7/01) - Duplicate Aid Match, Discontinue
• M20 003A (7/01) - Duplicate Aid Match, Deny
• M20_353C (6/98) - Fraud, Penalty Applied to AU
• M20_353D (6/98) - Fraud, Penalty Applied to AU
• M20_353F (6/98) - Fraud, Penalty Stops - Change
• M40_105 (11/14) - Failed to Provide SSN When Received or Failure to Cooperate
• M40_105A (11/14) - Failed to Provide SSN or proof of completed SSN Application
• M40_105B (7/98) - Change: Required Documentation Received, Immunization
• M40_105C (11/14) - Notice Of Action - Immunizations
• M40_105D (7/98) - Change: Required Documentation Received, School Attendance
• M40-105D1 (1/15) - Notice Of Action - School Attendance
• M40_105E (2/15) - Notice Of Action - School Attendance
• M40_105I (3/00) - Deny: SFIS Requirements, Failure to Cooperate
• M40_105J (3/00) - Deny: SFIS Requirements, Refusal to Cooperate
• M40-107 (6/11) - Addendum 1 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption - Use Until April 30, 2022
• M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40-107 (6/11) - Addendum 2 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption - Use Until April 30, 2022
• M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40_107A (11/02) - Other: CalWORKs 60-Month Time Limit, Time on Aid (no previous NOA issued)
• M40-107A (4/21) - Time On Aid (no previous NOa issued), Other - Use Starting May 1, 2022
• M40 107B (6/11) - Time on Aid at Redetermination
• M40-107B (4/21) - Time On Aid at Redetermination - Use Starting May 1, 2022
• M40_107C (6/11) - Time on Aid Between 42nd and 46th
• M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022
• M40 107D (6/12) - Time On Aid To Former CalWORKs Recipients
• M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients - Use Starting May 1, 2022
• M40_107E (4/04) - Change: CalWORKs 60-Month Time Limit, 60th month On Aid
• M40_107F (6/11) - Extender Met After 48th Month
• M40-107F (4/21) - Extended Beyond 60 Months of Aid - Use Starting May 1, 2022
• M40_107F1 (6/11) - Extender Beyond 60th month On Aid
• M40-107F1 (4/21) - Extender Met After 60th Month - Use Starting May 1, 2022
• M40_107F2 (6/11) - Extender Ended
• 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_107H (11/02) - Change: CalWORKs 60-Month Time Limit, 60th month on Aid MFG child only
• M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue
• M40_107J (11/02) - Partial Approval: CalWORKs 60-Month Time Limit, Time-Out Adult
• M40-107J (4/21) - Timed-Out Adult, Partial Approval - Use Starting May 1, 2022
• M40_107J1 (6/11) - Approval After 48 Months on Aid
• M40-107J1 (4/21) - Approval After 60 Months on Aid - Use Starting May 1, 2022
• M40_107K (6/11) - Increase Grant due to TOA Adjustment
• M40-107K (4/21) - Increase Grant due to TOA Adjustment - Use Starting May 1, 2022
• M40_118A (8/96) - Application Processing Deny
• M40-125B SAR (4/16) - Restore After a SAR7 Discontinuance
• M40-125C SAR (4/16) - Incomplete Semi-Annual Report (SAR7) Denial of Restoration
• M40 129B (11/09) - Full Payment - Approve
• M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve
• M40 129C (12/90) - Immediate Need -Deny - Miscellaneous
• M40-129D1 (11/14) - Procedural Requirements, 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 Prove 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_157A1 (5/91) - Incomplete Citizen/Alien Documentation: Approval
• M40_171A (11/14) - Failure to Cooperate - Deny
• M40_171B (1/97) - Refusal to Cooperate - Denial
• M40_171C (6/98) - Approve: Application Processing, Basic Approval
• M40_171D (6/18) - Basic Approval
• M40_171M (7/87) - Denial: Application Processing, Not a California Resident
• M40-181 (9/13) - SAWS 2 Redetermination Of Eligibility
• M40-181A (11/14) - SAWS 2 Redetermination/Other Essential Information
• M40-181C SAR (9/13) Notice Of Action - Balderas Reminder Notice
• M40_181D (5/91) - Denial: Application Processing, Not a California Resident
• M40_181E (11/14) - SAWS 2 PLUS Redetermination Immunizations/School Attendance, Change
• 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
• M41_401A (12/86) - Denial: Deprivation, No Deprivation
• M41_440F (6/98) - Deny: Deprivation, CalWORKs-U, 100 Hours Work Rule
• M41_450A (1/98) - Deprivation: Uniformed services - Deny
• M42_101B (11/14) - Age and School Requirements
• M42_101C (11/14) - Age and School Requirements, Discontinue
• M42-207A (10/15) - Over Property Limit, Deny
• M42-213A (11/14) - Restricted Account
• M42_221K (4/99) - Suspend: Property, Transfer w/out Fair Consideration
• M42_221L (4/00) - Suspend: Income, Transfer w/out Fair Consideration
• M42-431A4 (11/14) - No Eligible Noncitizen Status/Proof of Eligible Noncitizen Status, Discontinue
• M43_119E (1/98) - Sponsored Non-Citizen: Some needs Met - Change
• M43_119G (11/14) - Missing SAR 72, Change
• M43-119H (11/14) - Missing SAR 72, Discontinue
• M43_119I (7/98) - Change: Sponsored Alien, Deemed & Family Property
• M43_119J (7/98) - Change: Sponsored Alien, Deemed Property
• M43_119K (7/98) - Deny: Sponsored Alien, Deemed Property & Family Property
• M43_119L (7/98) - Deny: Sponsored Alien, Deemed Property
• M43_119M (1/98) - Sponsored non-Citizen: Deemed Income-Change
• M44_113A (6/98) - Change: Income, Change in Income
• M44_113G1 (6/98) - Change: Income, Change in Income
• M44-113H (11/12) - Change In Income
• M44_133D (6/98) - Change: Income, Change in Income
• M44_133Q (6/98) - Change: Income, Change in Income
• M44_133S (10/02) - Minor Parent Financial Eligibility (Change)
• M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval
• M44_133V (10/02) - Minor Parent Financial Eligibility (Suspend)
• M44-207I SAR (4/16) - Financial Eligibility
• M44_207J (6/98) - Deny: Income, Financial Eligibility Test
• M44-207K (5/20) – Financial Eligibility, Discontinue – Use Starting 6/1/2020
• M44-207K1 (5/20) - Minor Parent, Financial Eligibility
• M44_207L (6/98) - Suspend: Income, Financial Eligibility Test
• M44-207M (8/20) - Financial Eligibility, Deny
• M44-211A (12/19) - Temporary Shelter and Permanent Housing, Approve
• M44-211B (10/21) - Expanded Temporary HA For Applicants Fleeing DV, Approve
• M44-211D (9/23) - Temporary Shelter And/Or Permanent Housing
• 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_305 (9/97) - Minor Parent Change of Payee
• M44_307A (11/15) - Voucher/Vendor Payment, Other
• M44_307B (1/99) - Voucher/Vendor Payment
• M44_307C (7/98) - Voucher Vendor Payment
• 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_315B (9/98) - Change: Aid Payment Levels, ICT between Reg-2
• M44 315C (4/09) - Notice of Action - Four Percent Grant Reduction
• M44 316 (8/04) - No Change/Mid Quarter 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
• M44-316 SAR (4/25) - No Change/Mid-Period Reporting
• M44-316D SAR (9/13) - Notice Of Action - Change In Income
• M44-316E (10/16) - Mid-Period Change Due To The Death Of A Child
• M44-340 (2/23) - Underpayment Adjustment, Approval
• M44 340C (8/12) - Underpayment Adjustment
• M44-350A (11/11) - Overpayment Adjustment
• M44-350E (11/11) - Excess Property O/P and Adjustment (W/O Good Faith)
• M44-350F (11/11) - Excess Prop O/P (W/O Good Faith)
• M44_350G (11/11) - Excess Prop O/P Adjustment (With Good Faith)
• M44_350H (11/11) - Excess Prop O/P (W/Good Faith)
• M44 350I (11/11) - Notice of Overpayment
• M44-350I SAR (9/13) - Notice Of Overpayment
• M44-350J (3/12) - Overpayment To Be Stopped Effective February 1, 2012
• M44-350K (6/24) - EBT Replacement Denial
• M44-350L (12/18) - Notice Of Overpayment
• M44-350O (11/24) - Notice of Suspected Fraud
• M44 352A (11/11) - Notice of O/P and Demand
• M44 352C (11/11) - Overpayment Recovery
• M44 352D (11/11) - Overpayment Recovery
• M44 352G (11/11) - Demand Overpayment
• M44-352H (2/23) - Overpayment Adjustment 
• M44-352H SAR (9/13) Notice Of Action Overpayment Adjustment
• M44-352I (11/24) - Notice of Settled Overpayment
• M44-353 (11/24) - Notice Of Overpayment Discharge
• M44_401A (6/98) - Approve: Hardship Supplement RISP - MFG
• M44_401B (6/98) - Deny: Hardship Supplement RISP - MFG
• M81_215A (6/98) - DENY: Aid Payments, Diversion payment provided
• M81_215B (6/98) - DENY: Aid Payments, Diversion services provided
• M81_215D (6/98) - Change: Aid Payments, Diversion Repayment Stops
• M81_215E (6/11) - Time limit Diversion - Use Until April 30, 2022
• M81-215E (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M81_215F (6/11) - Time Limit Diversion - Use Until April 30, 2022
• M81-215F (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M82 506 (6/98) - Change: Assignment of Support Rights, Failure to Cooperate
• M82 506A (6/98) - Partial Approval: Assignment of Support Rights, Failure to Cooperate
• M82 510 (6/02) - Failure to Cooperate, Change
• M82 510A (6/98) - Change: Support Process/Assignment, Cooperate
• M82 812 (4/04) - Family Reunification/Zero Grant
• 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 832A (2/99) - Change: Aid Payments, Fleeing Felons
• M82 832B (2/99) - Partial Approval: Application Processing, Fleeing Felons
• M82 832E (4/15) - Eligible Person Leaving AU, Change
• M82 832F (4/15) - Eligible Person Leaving AU, Discontinue
• M82-832G (6/18) - Eligible/Mandatory/Optional Person Leaving AU
• M82-832H (10/20) - Child Does Not Meet Requirements (SB 380)
• M82 836A (8/91) - Denial: Au Composition, Unborn not Eligible for Aid
• M89_110 (1/98) - Exempt: Change
• M89_110A (1/98) - Non-Exempt Change
• M89_110B (1/98) - Exemption: Deny
• M89 130 (1/02) - Restricted Account, Discontinue
• M89_201 (11/96) - Minor Parent exemption: Deny
• MT42_101.2D (11/04) - Fry vs Saenz Lawsuit Age Requirement - Change
• MT42_101.2E (11/04) - Fry vs Saenz Lawsuit Age Requirement - Discontinue

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 Until May 31, 2022
• NA 200 (7/21) - Notice Of Action - Multipurpose - Include Budget - Use Starting June 1, 2022
• M44-207M (8/20) - Financial Eligibility, Deny
• NA 210 (5/20) - Discontinue, Suspend Financial Eligibility - Use Starting June 1, 2020
• NA 211 (1/00) - Notice of Action
• NA 213 (10/21) - Deny - Financial Eligibility
• NA 213A (8/20) – Notice Of Action – Deny – Financial Eligibility - Use Until May 31, 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 274E (6/11) - Notice Of Action Overpayment Computations For 1-1-98 to 6-30-2011
• NA 274F (6/11) - Notice Of Action - Overpayment Amount Owed (For Overpayments Occurring on or after 7/1/2011)
• 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 275 (4/99) - Continuation Page - Overpayment Adjustment Computation - Cash Aid
• NA 281 (6/11) - Notice Of Action Underpayment Amount Owed (For Underpayments Occurring on or After 1-1-98 thru 6-30-2011)
• NA 281A (6/11) - Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 7/1/2011)
• 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 (12/20) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring On Or After 6-1-2021)
• 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 (12/20) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Tests - Use Starting June 1, 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 421 (6/21) – Assistance Dog Special Allowance (ADSA) - Notice Of Action - Approval
• NA 403 (2/23) - Notice Of Action - Approval, Change or Discontinued - For Resource Families, Including Homes Certified By A Foster Family Agency, County Approved Relative Homes, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians, Intensive Treatment Foster Care and/or Intensive Services Foster Care, Group Homes and Short-Term Residential Therapeutic Programs
• NA 403A (4/17) Notice Of Action – Change For Kinship - Guardians Only
• NA 422 (11/21) - Assistance Dog Special Allowance (ADSA)
• NA 422L (1/22) - Assistance Dog Special Allowance (ADSA) Notice of Action – Denial
• NA 530 (4/11) - Notice of Action 48-Month Time Limit- Use Until April 30, 2022
• 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 (12/20) - Notice Of Action - Continuation Page - 48-Month Time Limit - Includes Budget - Use Starting June 1, 2021
• NA 531 (7/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget - Use Starting June 1, 2022
• NA 532 (7/19) - Notice Of Action - Continuation Page - 48-Month Time Limit Discontinue - Use Starting June 1, 2020
• 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 533 (5/11) - Notice Of Action - CalWORKs "Child-Only" Time On Aid Grant Cut
• NA 534 (5/11) - Notice Of Action - CalWORKs "Child-Only" Time On Aid Grant Cut Continued
• NA 690 (3/03) – IHSS Notice of Action
• 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 791 (10/23) - Notice of Action - Approval/Denial/Change
• 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 (3/25) - Notice Of Action - Transportation Approval
• NA 821 (11/20) - Notice Of Action - Transportation Approval/Denial
• NA 822 (7/16) - Notice of Action - Transportation Change
• NA 823 (8/00) - Ancillary Approval/ Denial1
• NA 824 (4/99) - Notice of Action
• NA 825 (8/00) - Notice Of Action - Payment Adjust Transportation
• NA 827 (7/99) - Notice of Action - Recoupment of Unused Advance Payment
• NA 828 (7/99) - Notice of Action - Transportation and Ancillary Exp Overpayment
• NA 832 (3/20) - 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 840 (3/14) - Notice Of Action - Welfare To Work Plan
• NA 840A (10/03) - Notice Of Action - Cash Aid
• 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 843 (6/99) - Notice of Action - Inelegible
• NA 844 (8/99) - 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 991 (10/03) - Refugee Cash Assistance (RCA)/Entrant Cash Assistance (ECA) MC-Decrease/Expiration (Time-Expiration)
• NA 992 (5/03) - Refugee Cash Assistance (RCA) Application Approval
• NA 995 (5/13) - Food Stamp Notice Of Denial/Disqualification For The California Food Assistance Program
• NA 1208 (2/00) - Notice Of Action - Basic Approval
• NA 1209 (2/02) - Notice of Action - Change In The Amount Of Kin-Gap Payment
• NA 1210 (4/02) - Notice Of Action - Discontinue
• NA 1211 (2/00) - Notice Of Action - Denial
• NA 1212 (2/00) - Notice Of Action - Discontinue Property
• NA 1213 (2/00) - Notice Of Action - Discontinue Restricted Account
• NA 1214 (2/00) - Notice Of Action - Change Under/Overpayment
• 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 (7/01) - 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 (9/11) - Notice of Action (Continued) Quarterly Reporting Budget
• NA 1239 AR (7/19) - Notice Of Action - Continuation Page - Annual Report Budget - Use Until May 31, 2021
• 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 1250 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Approval
• NA 1250L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval
• NA 1251 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation
• NA 1251L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation
• NA 1252 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Denial
• NA 1252L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Denial
• NA 1253 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Change
• NA 1253L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change
• NA 1254 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation
• NA 1254L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation
• NA 1255 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Termination
• NA 1255L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Termination
• NA 1256 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cost
• NA 1256L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cost
• NA 1257 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Multi
• NA 1257L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Multi
• NA 1261 (1/16) - Notice Of Action - Form and Instructions - For Group Homes, Short-Term Residential Treatment Centers, Foster Family Agencies, Transitional Housing Placement-Plus Foster Care and Transitional Housing Placement Program
• NA 1261A (3/20) - Notice Of Action – For Approved Relatives, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians or Non-Minor Dependents Residing In A Supervised Independent Living Setting
• NA 1261B (1/16) - Notice of Action - Form And Instructions - For Kinship-Guardians Only
• NA 1263 (8/11) - Notice of Action - Overissuance Budget Worksheet
• NA 1267 (4/13) - CalFresh Informing Notice Of Receiving Intercounty Transfer
• NA 1268 (4/13) - CalFresh Informing Notice Of Sending Intercounty Transfer
• NA 1269 (11/11) - Notice of Action - Approve Non-Minor Dependent
• NA 1270 (11/11) - Notice of Action - Discontinue Non-Minor Dependent
• NA 1271 (5/14) - Notice Of Action - Denial Of Home Assessment/Approval
• 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 1277 (1/16) - Notice Of Action - Approved Relative Caregiver (ARC) Overpayment
• NA 1278 (11/16) - Notice Of Action - Approve Approved Relative Caregiver (ARC) Payment
• NA 1279 (11/16) - Notice Of Action - Deny Approved Relative Caregiver (ARC) Payment
• NA 1280 (11/16) - Notice of Action - Discontinue Approved Relative Caregiver (ARC) Payment
• NA 1281 (11/16) Notice Of Action - Change Approved Relative Caregiver (ARC) Payment
• 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 56 (12/06) - The In-Home Supportive Services Program
• 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
• PUB 203 (1/04) - In-Home Supportive Services - Guide to Workers' Compensation Benefits for Individual Providers
• PUB 269 (2/18) - California Child Passenger Safety Law - (8.5" x 11")
• PUB 269 (2/18) - California Child Passenger Safety Law - (8.5" x 14")
• PUB 271 (2/17) - Never Shake a Baby Brochure
• PUB 271 (2/17) - Never Shake a Baby Brochure (Black & White)
• PUB 273-A2 (2/21) - Shaken Baby Syndrome Poster - ( 24" x 36")
• PUB 275 (4/07) - Family Planning...Making the Commitment for a Healthy Future
• NA 281D (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2021 and 5-31-2022)
• PUB 294 (10/22) - Assistance Dog Special Allowance (ADSA) Program Fact Sheet
• PUB 294L (10/22) - Assistance Dog Special Allowance (ADSA) Program Fact Sheet (Large Print)
• PUB 325 (12/16) - Your Right To Make Decisions About Medical Treatment (Print 8 1/2 X 14)
• PUB 337 (9/12) - Statewide Fingerprint Imaging System (SFIS)
• PUB 367 (4/13) - Reach For Your Dreams With Cal-Learn
• PUB 370 (4/19) - Public Assistance Benefits For Asylees In California
• PUB 373 (Print 8.5 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 393 (12/06) - Notification of Parents' Rights - Child Care Center
• PUB 394 (12/06) - Notification of Parents' Rights - Family Child Care Home
• PUB 400 (8/23) - Safely Surrendered Baby Campaign Brochure
• PUB 400C-1 (6/17) - Safely Surrendered Baby Law - Know Your Rights Poster
• PUB 403 (6/05) - We Gladly Accept EBT (Poster size 11" x 17")
• PUB 420 (10/08) - Supplemental Security Income (SSI) Information for Transitioning Foster Youth
• PUB 421 (10/08) - Supplemental Security Income (SSI) for Youth with Disabilities
• PUB 422 (10/08) - Supplemental Security Income (SSI) for Foster Youth with Disabilities
• PUB 428 (12/24) - It's Your Money - Get It - The State and Federal Earned Income Tax Credit (EITCs)
• PUB 428A (1/17) - Client Needs Survey
• PUB 429 (12/24) - California EITC is Here! Claim Your 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 (Requires 8 1/2" x 14" paper printed landscape)
• PUB 463 (10/13) - Education Travel Reimbursement
• PUB 470 (4/21) - 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 501 (2/16) - Complaint Investigation Process - Statewide Children's Residential Program -County Licensed Foster Parents
• PUB 511 (2/25) - 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
• 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 523 (4/25) - Parent Appeal Information Pamphlet
• 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

• QR 2103 (11/11) - Reminder For Teens Turning 18 Years Old

R

• RAD 03 (2/21) – Suspected Unemployment Insurance Fraud And identity Theft Information
• 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 (10/22) - Resource Family Application
• RFA 01B (7/19) - Resource Family Criminal Record Statement
• RFA 03 (8/22) - Resource Family Home Health And Safety Assessment Checklist
• RFA 05 (1/23) - Resource Family Approval - Written Report
• RFA 05A (8/22) - Resource Family Approval Certificate
• RFA 07 (2/18) - Resource Family Approval (RFA) Health Screening
• RFA 09 (5/24) - 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 10E (9/24) - Resource Family Approval Request To Transfer Or Surrender Approval - FFA Closure
• RFA 11 (12/19) – Resource Family Approval Statement Acknowledging Requirement To Report Child Abuse
• RFA 12 (3/21) - Resource Family Approval Documented Alternative Plan (DAP)
• RFA 13 (6/24) - Resource Family Approval - Video Camera Agreement Form
• RFA 105 (11/19) – Notice of Action – Issuance Emergency Caregiver Funding
• RFA 105A (11/19) – Notice of Action – Discontinue Emergency Caregiver Funding
• RFA 809 (5/24) - Resource Family Visit Record
• RFA 809C (5/24) - Resource Family Visit – Corrective Action Plan
• RFA 811 (8/17) - Confidential Names
• RFA 812 (6/17) - Detail Supportive Information
• RFA 9099 (5/24) - Complaint Investigation Report
• RFA 9099C (5/24) - Complaint Investigation Report - Corrective Action Plan
• RS 3 (5/03) - Service Provider Referral/Notification Form
• RS 36 (3/08) - Employment And Training Requirements For Refugee Cash Assistance (RCA)

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 (12/23) - 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 (12/23) - 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 22 (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid and/or CalFresh
• SAR 22LP (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid And/Or CalFresh - (Large Print)
• 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 152 (9/19) - Placement Agency - THP Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In THP Plus Foster Care Provider
• SOC 153 (9/19) - Placement Agency - Foster Family Agency Agreement Nonminor Dependent Placed by Agency in Foster Family Agency
• SOC 154 (9/19) - Agency — Group Home Agreement Child Placed by Agency in Group Home
• SOC 155 (5/99) - Voluntary Placement Agreement - Placement Request
• SOC 156 (9/19) - Agency — Foster Parents Agreement Child Placed by Agency in Foster Home
• SOC 156A (9/19) - 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 (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 369 (12/10) - Agency-Relative Guardianship Disclosure8
• 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 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 500 (4/18) - Level Of Care (LOC) Digital Scoring Form
• SOC 501 (12/17) - Levels Of Care (LOC) Rate Determination Matrix
• 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 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 (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 827 (12/06) - In-Home Supportive Services (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 (9/22) - Request for Conditional CAPI After Naturlization Pending SSI/SSP Eligiblity Determination
• SOC 831 (10/18) - IHSS Provider Letter
• SOC 832 (1/13) - Notice of Child Abuse Central Index Listing
• SOC 833 (3/12) - Grievance Procedures for Challenging Reference to the Child Abuse Central Index
• 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 (6/23) - In-Home Supportive Services (IHSS) Designation Of Authorized Representative
• SOC 839A (6/23) - In-Home Supportive Services (IHSS) Designation of Signatory for TPRD
• SOC 839B (6/23) - In-Home Supportive Services (IHSS) Cancellation of Authorized Representative-TPRD Signatory
• 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 (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 (2/23) - 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
• 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 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 (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 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 (1/23) - 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 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 Timesheet Service Or Telephone Timesheet System
• 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 2 (8/24) - CDSS Disaster Recovery Program (SSGP FAQ)
• SSGP 45 (5/24) - The State Supplemental Grant Program (SSGP)
• SSGP 46 (1/25) - The State Supplemental Grant Program Timeline
• 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 (3/24) - Notice Of Action And Right To Request A State Hearing On Interim Assistance

T

• TEMP 513 (4/22) - Important Information For CalWORKs Families
• 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 2177 (11/99) - CFAP Work Rule
• 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 2206 (4/02) - Notice Of Action
• TEMP 2207 (5/02) - Notice Of Action
• TEMP 2208 (4/02) - Notice Of Action
• TEMP 2209 (4/02) - Notice Of Action
• TEMP 2211 (4/02) - Notice Of Action
• TEMP 2212 (5/02) - Notice Of Action
• 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 (6/24) - State Law Changes Maximum Aid Payment (MAP) Levels For Cash Aid Recipients
• 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
• 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
• TEMP 3015A (2/20) - Franchise Tax Board (FTB) Annual Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3016 - Spanish
• 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 LIC 9163 (2/99) - Live Scan
• 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 820A (5/02) - Notice Of Action
• TEMP NA 1225 (8/01) - Underpayment Computation
• TEMP NA 1228 (6/01)
• TEMP NA 1229 (6/01)
• 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 (4/23) – CalFresh Notice Of Action 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 (1/23) - Transitional Independent Living Plan & Agreement
• TLR 03 (10/23) - Trustline To Community Care Licensing Criminal Background Clearance Transfer Request
• TLR 301E (3/11) - Trustline Reference Request - Exemption
• TLR 9163G (8/23) - TrustLine Registry Application
• TM44-111A - (4/13) - Income Disregards Change
• TM44-314 (8/16) - Basic Approval
• 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
• TM44-315M (7/22) - 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

• Welfare to Work Handbook
• 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 1 (12/05) - Welfare To Work Plan Rights and Responsibilities
• WTW 2 (6/24) - Welfare-To-Work Plan Activity Assignment
• WTW 4 (8/04) - Notice to Other Parent
• WTW 4A (4/24) - Notice to Other Parent - Use Starting January 1, 2025
• WTW 5 (5/23) - Welfare-To-Work Program 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 16A (12/20) - Grant-Based OJT Income Examples For Region 1 - Use Starting June 1, 2021
• WTW 16A (3/22) - Grant-Based OJT Income Examples For Region 1 - Use Starting June 1, 2022
• WTW 16B (7/19) - Grant Based OJT Income Examples For Region 2 - Use Starting June 1, 2020
• WTW 16B (12/20) - Grant-Based OJT Income Examples For Region 2 - Use Starting June 1, 2021
• 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 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 (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 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 51 (1/21) - Welfare To Work Noncompliance Checklist Tool - Use Starting May 1, 2022
• WTW 112 (3/21) - Verification: Caring for a Household Member
• WTW 246 (5/25) - Employment Workshop & Job Search Notice
• WTW 2490 (11/20) - Non-Receipt Of WTW Attendance/Progress Report
• 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