CDSS Programs Refugees Forms

Forms

  • NA 991 - Refugee Cash Assistance (RCA)/Entrant Cash Assistance (ECA) MC-Decrease/Expiration (Time-Expiration)
  • NA 992 - RCA Application Approval
  • RCA and Refugee Services (RS) forms
  • RCA 43 - Refugee Cash Assistance (RCA) Notice Of A Participation Problem
  • RCA 44 - Refugee Cash Assistance (RCA) Notice Of No Good Cause Determination And Compliance Plan Appointment
  • RS 1 - Refugee Settlement Program Services Application And Assessment Information
  • RS 3 - Service Provider Referral/Notification Form
  • RS 3A - Client Tracking
  • RS 18 - Refugee Services - Information Transmittal
  • RS 36 - Employment And Training Requirements For Refugee Cash Assistance (RCA)
  • RS 50: Exhibit C - Services Report: Employment Services (Schedule C) **(Not to be used for county reporting), Instructions (Exhibit C-1) and Narrative form (Schedule A)
    • Due to the RS 50 form not being ADA accessible, please email RPB Reports for a mailed copy.
  • RS 51: Exhibit C-2 - Caseload Movement Report (Schedule B) **(Not to be used for county reporting)
    • Due to the RS 51 form not being ADA accessible, please email RPB Reports for a mailed copy.
  • RS 52 - Claim for Reimbursement (see ACIN I-42-09 for reporting details)
  • Additional CDSS Forms and Translations

Please contact your county analyst for the latest reporting forms or if you have any questions regarding these forms. For the County Operations & Performance Unit staff responsible for your county, either call (916) 654-4356 or email. Some documents are in Adobe Portable Document Format (PDF). Please see Tips for Using Adobe PDF Files for details.