Welfare Advocate Forms

Hearings

pdf State Hearing Conditional Withdrawal Form – Fillable

In CCWRO Hearings Forms

” STATE OF CALIFORN IA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES WITHDRAWAL CONDITIONAL WITHDRAWALS OF REQUEST FOR HEARING I, , the undersigned do hereby: Withdraw my request for a state hearing before the State Department of Social Services. I understand that by withdrawing my request, I lose my right to a hearing on that request. I also understand that by withdrawing my request for hearing, aid which has been paid because of the request will stop without further notice. I may, however, file a new hearing request raising the identical issue provided that the new request is timely per Manual of Policies and Procedures Section 22-009. Conditionally withdraw my request for a state hearing before the State Department of Social Services. I understand that by conditionally withdrawing my request for hearing, aid which has been paid because of the hearing request will stop without further notice. I understand that the county will issue a redetermination notice within 30 days and that I must request a hearing within 90 DAYS of the county’s notice if I am not satisfied with the county’s reconsideration of my case. Upon such renewal, I shall have the same rights I would have had if I had not signed this conditional withdrawal. NOTE: A conditional withdrawal must provide that the actions of both parties will be completed within 30 days. The reasons for or conditions of this withdrawal are: Signed Signed (County Representative) (Claimant) (County Address) (City) (Telephone Number) (Zip Code) (Date) (Date) (Zip Code)(City) (Address) (Telephone Number) NOTE: A Conditional Withdrawal must also be signed by a County Representative or it is invalid. DPA 315 (7\/99) County Case No: Filing Date: Hearing Date: Hearing Time: Case Name: State Hearing No: County: box 1: Off case name: state hearing no: county: county case no: filing date: hearing date: hearing time: name 1: box 2: Off box 3: Off box 4: Off reason ln 1: reason ln 2: reason ln 3: reason ln 4: reason ln 5: reason ln 6: date signed 1: date signed 2: claimant address: county address: city\/state: city\/state 2: zip code: zip code 2: phone number 1: phone number 2: ”

pdf How to get a State Hearing Tape fillable(11 2020)

In CCWRO Hearings Forms

” FOR ASSISTANCE CONTACT CCWRO @ 1111 Howe Avenue, Suite 635, Sacramento, CA 95825 Tel. 916-736-0616 Email: [email protected] How to get copy of a state hearing tape? DSS POLICY: DSS will provide a copy of the hearing tape free of charge once the hearing decision has been released. DSS requests that claimants and their authorized representatives write to: DSS, SHD State Hearings Support Section P.O. box 944243, M.S. 9-17-37 Sacramento, CA 95814 or Email it to:[email protected] The request for a hearing tape must include the following information: Name of the Claimant ___________________________________ State Hearing # ___________________________________ Date of the Hearing ___________________________________ Name of the Judge ___________________________________ Requestor information if different than the claimant Name ______________________________________________ Agency ______________________________________________ Address ______________________________________________ City __________________________ ZIP ________________ Date: Requestor Signature Agency: Address: City: ZIP: Name: Name12: Name13: Name14: date: Namemlnlkjn: ”

pdf California Department of Social Services Expedited Hearing Request Form

In CCWRO Hearings Forms

” EXPEDITED STATE HEARING REQUEST BEFORE THE DEPARTMENT OF SOCIAL SERVICES I, the undersigned, hereby request an expedited hearing against the county of __________________________________ for the county action\/inaction regarding: Please check the box that applies to you Program CWD Action CalWORK Immediate Need CalFresh\/Food Stamp Expedited Services CalWORKs Homeless Assistance Immediate medical assistance Child Care needed to work or attend school Books needed to not drop classes Transportation needed to work or attend school Other: Please Specify ______________________________________ ______________________________________ ______________________________________ ________________________________ ________________________________ ________________________________ Claimant and Representative Information ________________________________________________________________________ Claimant Name Last Name Case #\/SSN# ________________________________________________________________________ Claimant Address ________________________________________________________________________ Claimant Phone Number Email Address I want to have the person below represent me at this hearing: ________________________________________________________________________ Name of Authorized Representative Name of Organization, if any ________________________________________________________________________ Authorized Representative Address ________________________________________________________________________ Authorized Representative Phone Number Email Address ____________________________________________________________ ______________________ Claimant Signature Date for the county actioninaction regarding: Program: CWD ActionCalWORK Immediate Need: CWD ActionCalFreshFood Stamp Expedited Services: CWD ActionCalWORKs Homeless Assistance: CWD ActionImmediate medical assistance: CWD ActionChild Care needed to work or attend school: CWD ActionBooks needed to not drop classes: CWD ActionTransportation needed to work or attend school: Other Please Specify 1: Other Please Specify 2: Other Please Specify 3: 1: 2: 3: Claimant: Name: Last Name: Case SSN: Claimant Address: Claimant_2: Phone Number: Email Address: Name of Authorized Representative: Name of Organization if any: Authorized Representative Address: Authorized Representative: Phone Number_2: Email Address_2: undefined_8: Check Box1: Off Check Boxar: Off Check Box2: Off Check Box3: Off 4134: Off Check5: Off Check Box6: Off qergv2: Off Check Box1=4: Off ”

IHSS

pdf IHSS- CCWRO IHSS initial Application form

In IHSS

” ATTN: IHSS Screener Letter of Request for IHSS Services Authorization to A.R. FORM Name________________________________________________________________ Address _____________________________________________________________ DOB ___________ SSN _________ _____ _________ Contact Number Sex : Male __ Female ___ Language: ___Armenian ___Russian ___Spanish ___other The applicant is receiving SSI\/CAPI benefits at this time? Yes__No__ Living Arrangements : ___Self ___Relative ___Spouse ___Family How many people at this address? _____ Reason for Seeking IHSS Assistance Various medical problems. The applicant will provide medical verifi- cation of this need. Please provide the applicant with the form needed so the applicant can have the doctor complete the form and the applicant will provide the county with the medical verifica- Types of Assistance Needed __ Domestic Services __ Shopping for Food __ Doctor Visits __ Preparation of Meals __ Meal Cleanup __ Pers. Hygiene __ Dressing __ Feeding __ Ambulation __ Moving in and out of bed __ Respiration __ Bowel and Bladder __ Other Shopping & Errants __ Forgetful __ Disoriented __ Loses things __ Confusion __ Protective Services Dated: ________ Signature of applicant _________________________________________ Regarding Waiver of Confidentiality. PLEASE TAKE NOTICE that I hereby REFUSE to waive my rights to confidentiality. I also refuse to sign the HIPPA release of information form, also known as the Form 2099 series. Any signing of such forms will be obtained through coercion by DHS and they are invalid, void and immoral. I, ______________________________________________________, hereby authorize __________________________, at _______________________________________________________________________________________________ or any other person\/attorney designated him or __________________________________________________________, to be my authorized representative in this matter or any other matter relative to my public assistance case, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of litigation. This authorization shall also be construed as an authorization to release any and all information to __________________ or any person designated by them, including an attorney. I further authorize _________________________________________________________________________________ or any other persons designated by them to apply for and represent me during all aspects of the application process or any other matter relative to the process of eligibility determination for any and all benefits that I and\/or my family may be eligible for. Text2: Text3: Text4: Text5: Text6: Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box19: Off Check Box20: Off Check Box21: Off Check Box22: Check Box23: Check Box24: Off Check Box25: Off Check Box26: Off Check Box27: Off Check Box28: Check Box29: Off Check Box30: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box35: Off Text36: Text37: Name: Text7: Text1: Has Medi-Cal Text8: Check Box36: Off Text38: advocate: adv address: ”

pdf IHSS Provider Travel Time Claim (11 2020)

In IHSS

” IHSS Provider Travel Time Claim ACL 17-25 Date Name of Doctor Address Travel Time from home to medical appointment Estimated on duty wait time Mode of transportation Car Bus ___________________________________ _______________________________ Provider Signature Date____ IHSS Beneficiary Signature Date:_____ DateRow1: Name of DoctorRow1: AddressRow1: Travel Time from home to medical appointmentRow1: Estimated on duty wait timeRow1: DateRow2: Name of DoctorRow2: AddressRow2: Travel Time from home to medical appointmentRow2: Estimated on duty wait timeRow2: DateRow3: Name of DoctorRow3: AddressRow3: Travel Time from home to medical appointmentRow3: Estimated on duty wait timeRow3: DateRow4: Name of DoctorRow4: AddressRow4: Travel Time from home to medical appointmentRow4: Estimated on duty wait timeRow4: DateRow5: Name of DoctorRow5: AddressRow5: Travel Time from home to medical appointmentRow5: Estimated on duty wait timeRow5: DateRow6: Name of DoctorRow6: AddressRow6: Travel Time from home to medical appointmentRow6: Estimated on duty wait timeRow6: DateRow7: Name of DoctorRow7: AddressRow7: Travel Time from home to medical appointmentRow7: Estimated on duty wait timeRow7: DateRow8: Name of DoctorRow8: AddressRow8: Travel Time from home to medical appointmentRow8: Estimated on duty wait timeRow8: DateRow9: Name of DoctorRow9: AddressRow9: Travel Time from home to medical appointmentRow9: Estimated on duty wait timeRow9: DateRow10: Name of DoctorRow10: AddressRow10: Travel Time from home to medical appointmentRow10: Estimated on duty wait timeRow10: DateRow11: Name of DoctorRow11: AddressRow11: Travel Time from home to medical appointmentRow11: Estimated on duty wait timeRow11: DateRow12: Name of DoctorRow12: AddressRow12: Travel Time from home to medical appointmentRow12: Estimated on duty wait timeRow12: DateRow13: Name of DoctorRow13: AddressRow13: Travel Time from home to medical appointmentRow13: Estimated on duty wait timeRow13: DateRow14: Name of DoctorRow14: AddressRow14: Travel Time from home to medical appointmentRow14: Estimated on duty wait timeRow14: DateRow15: Name of DoctorRow15: AddressRow15: Travel Time from home to medical appointmentRow15: Estimated on duty wait timeRow15: Prov: der S: gnature: Date: IHSS Benefic: ary S: gnature_2: Date_2: Check Box1: Off Check Box2: Off ”

pdf IHSS Provider Change Request form – 11-2020

In IHSS

” IHSS Provider Change Request Form CURRENT PROVIDER Recipient Provider NEW PROVIDER Recipient New Provider New Provider DOB New Provider SSN New Provider Address New Provider Phone New Provider Email Date: _______ Signatute________________________________________________ Authorization Form I, ______________________________, hereby authorize CCWRO & Kevin Aslanian, 1111 Howe Ave., Sacramento, Suite 635, CA 95825 Tel. – 916-736-0616 FAX – 916-736-2645 or any other person\/attorney designated by him, to be my authorized representative, and to represent me, relative to my public social services matter, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to CCWRO or any person designated by them, including an attorney, to review my case file, including my IHSS case records. I further authorize CCWRO or any other persons designated by them to apply for and represent me during all aspects of the application process or any other matter relative to the process of eligibility determination for any and all benefits that I and\/or my family may be eligible for. Dated: __________________ Signature__________________________________ CURRENT PROVIDER: undefined: NEW PROVIDER: undefined_2: New Provider DOB: New Provider SSN: New Provider Address: New Provider Phone: New Provider Email: Date: Dated: undefined_3: ”

pdf IHSS Paramedical Form SOC 321 with CCWRO addendum

In IHSS

” STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REQUEST FOR ORDER AND CONSENT – PARAMEDICAL SERVICES TO: Dear Doctor: This patient has applied for In-Home Supportive Services (IHSS) and stated that he\/she needs certain paramedical services in order for him\/her to remain at home. You are asked to indicate on this form what specific services are needed and what specific condition necessitates the services. In-Home Supportive Services is authorized to fund the provision of paramedical services, if you order them for this patient. For the purpose of this program, paramedical services are activities which, due to the recipient’s physical or mental condition, are necessary to maintain the recipient’s health and which the recipient would perform for himself\/herself were he\/she not functionally impaired. These services will be provided by In-Home Supportive Services providers who are not licensed to practice a health care profession and will rarely be training in the provision of health care services. Should you order services, you will be responsible for directing the provision of the paramedical services. Your examination of this patient is reimbursable through Medi-Cal as an office visit provided that all other applicable Medi- Cal requirements are met. If you have any questions, please contact me. DATE SOC 321 (11\/99) PATIENT’S NAME MEDI-CAL IDENTIFICATION NUMBER SIGNED TITLE TELEPHONE NUMBER TO BE COMPLETED BY LICENSED PROFESSIONAL NAME OF LICENSED PROFESSIONAL OFFICE TELEPHONE OFFICE ADDRESS (IF NOT LISTED ABOVE) TYPE OF PRACTICE TYPE OF PRACTICE \u25a0 Physician\/Surgeon \u25a0 Podiatrist \u25a0 Dentist CONTINUED ON BACK RETURN TO: (COUNTY WELFARE DEPARTMENT) Does the patient have a medical condition which results in a need for IHSS paramedical services? Is YES, list the condition(s) below: \u25a0 YES \u25a0 NO List the paramedical services which are needed and should be provided by IHSS in your professional judgement. * Indicate the number of times a service should be provided for a specific time period: (Example: two times daily, etc.) Additional comments: SEE ADDENDUM TO THIS SOC 321 CERTIFICATION \u25a0 IF CONTINUED ON ANOTHER SHEET, CHECK HERE I certify that I am licensed to practice in the State of California as specified above and that this order falls within the scope of my practice. In my judgement the services which I have ordered are necessary to maintain the recipient’s health and could be performed by the recipient for himself\/herself were he\/she not functionally impaired. I shall provide such direction as is needed, in my judgement, in the provision of the ordered services. I have informed the recipient of the risks associated with the provision of the ordered services by his\/her IHSS provider. PATIENT’S INFORMED CONSENT I have been advised of risks associated with provision of the services listed above and consent to provision of these services by my In-Home Supportive Services provider. SIGNATURE DATE SIGNATURE DATE \u25bc \u25bc TYPE OF SERVICE TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMED FREQUENCY* HOW LONG SHOULD THIS SER- VICE BE PROVIDED? # OF TIMES TIME PERIOD ADDENDUM TO SOC 321 Type of Paramedical Service How many times a Day? Time to do the service each time How many months\/years? injections breathing treatments, nebulizer pulmonary toileting (pounding lung areas of back and chest to loosen secretions catheter changes or helping void urine with a catheter ostomy or bricker bag irrigation or changes and cleaning and maintaining the stoma site range of motion exercises and other home therapy programs prescribed by a physician nasal-gastric tube or G-Tube feedings & care of stoma site skin and wound care if there is a decubitus ulcer (bed or pressure sore) or a diabetes related wound or, if the person has a history of ecubiti, checking the body for hot spots that could turn into a decubitus ulcer including tracheal (deep) suctioning bowel program for those with spinal cord injuries or neurological bowel program for those with spinal cord injuries or neurological impairment impacting the gastro-intestinal system digital stool removal insertion of suppositories or administration of an enema adjustment, monitoring and connecting tubing and ventilator; C- PAP or BiPAP machine adjustment, putting on mask CERTIFICATION – I certify that I am licensed to practice in the State of California as specified above and that this order falls within the scope of my practice. In my judgement the services which I have ordered are necessary to maintain the recipient’s health and could be performed by the recipient for himself\/herself were he\/she not functionally impaired. I shall provide such direction as is needed, in my judgement, in the provision of the ordered services. I have informed the recipient of the risks associated with the provision of the ordered services by his\/her IHSS provider. SIGNATURE DATE \u25bc SOC321-Paramedical form ADDENDUM TO SOC 321 TYPE OF SERVICERow1: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow1: OF TIMESRow1: TIME PERIODRow1: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow1: TYPE OF SERVICERow2: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow2: OF TIMESRow2: TIME PERIODRow2: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow2: TYPE OF SERVICERow3: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow3: OF TIMESRow3: TIME PERIODRow3: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow3: TYPE OF SERVICERow4: TIME REQUIRED TO PERFORM THE SERVICE EACH TIME PERFORMEDRow4: OF TIMESRow4: TIME PERIODRow4: HOW LONG SHOULD THIS SER VICE BEPROVIDEDRow4: Type of Paramedical Service: How many times a Dayi n j ections: Time to do the service each timei n j ections: How many monthsyearsi n j ections: How many times a Daybreath i ng treatments nebulizer: Time to do the service each timebreath i ng treatments nebulizer: How many monthsyearsbreath i ng treatments nebulizer: How many times a Daypu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: Time to do the service each timepu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: How many monthsyearspu l monary to i l eting pound i ng l ung areas of back and chest to l oosen secretions: How many times a Daycatheter changes or he l p i ng vo i d ur i ne w i th a catheter: Time to do the service each timecatheter changes or he l p i ng vo i d ur i ne w i th a catheter: How many monthsyearscatheter changes or he l p i ng vo i d ur i ne w i th a catheter: How many times a Dayostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: Time to do the service each timeostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: How many monthsyearsostomy or br i cker bag i rr i gation or changes and c l ean i ng and ma i nta i n i ng the stoma s i te: How many times a Dayrange of motion exerc i ses and other home therapy programs prescr i bed by a physician: Time to do the service each timerange of motion exerc i ses and other home therapy programs prescr i bed by a physician: How many monthsyearsrange of motion exerc i ses and other home therapy programs prescr i bed by a physician: How many times a Daynasalgastr i c tube or GTube feed i ngs care of stoma s i te: Time to do the service each timenasalgastr i c tube or GTube feed i ngs care of stoma s i te: How many monthsyearsnasalgastr i c tube or GTube feed i ngs care of stoma s i te: cer: How many times a Dayi nc l ud i ng trachea l deep suction i ng: Time to do the service each timei nc l ud i ng trachea l deep suction i ng: How many monthsyearsi nc l ud i ng trachea l deep suction i ng: How many times a Daybowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: Time to do the service each timebowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: How many monthsyearsbowe l program for those w i th sp i na l cord i n j ur i es or neurological bowe l program for those w i th sp i na l cord i n j ur i es or neuro l og i ca l i mpa i rment i mpacting the gastro i ntestina l system: How many times a Dayd i g i ta l stoo l remova l: Time to do the service each timed i g i ta l stoo l remova l: How many monthsyearsd i g i ta l stoo l remova l: How many times a Dayi nsertion of suppos i tor i es or adm i n i stration of an enema: Time to do the service each timei nsertion of suppos i tor i es or adm i n i stration of an enema: How many monthsyearsi nsertion of suppos i tor i es or adm i n i stration of an enema: How many times a Dayad j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: Time to do the service each timead j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: How many monthsyearsad j ustment mon i tor i ng and connecting tub i ng and venti l ator CPAP or B i PAP mach i ne ad j ustment putting on mask: qr3: Off rveew: Off Check Box2: Off Check Box3r3: Off Check Box3 v1: Off Check Box3v3r3r1: Off Text1q: Text1w: Text15: Text16: Text17: Text18: Text19: vrr3: Text1: Text20: Text201: Text202: Text203: qerrv: qrwvr3t490: ”

pdf IHSS Advance Payment Request form

In IHSS

” REQUEST FOR IHSS ADVANCE PAY TO: County of _______________________ Name of Social Worker: ______________________________________ IHSS Case # _______________________________________ I, (name of IHSS beneficiary) _____________________________________________________ request advance pay effective immediately. Thank you for your consideration of my request for reassessment. Dated:________ ___________________________________________ Signature of IHSS Recipient\/Representative FORM INSTRUCTION: This form should be mailed or emailed to the IHSS beneficiary’s social worker anytime the IHSS beneficiary. If the county does not act on this request within 30 days file for a state hearing at: CCWRO.ORG IHSS Advance Pay State Regulations MPP 30-769.731 Severely impaired recipients as defined under Section 30-753, shall have the option of choosing to directly receive their payment at the beginning of each authorized month. Such payment shall be the net amount exclusive of the appropriate withholdings. MPP 30-701(s) (1) Severely Impaired Individual means a recipient with a total assessed need, as specified in Section 30-763.5, for 20 hours or more per week of service in one or more of the following areas: (A) Any personal care service listed in Section 30-757.14. (B) Preparation of meals. (C) Meal cleanup when preparation of meals and consumption of food (feeding) are required. (D) Paramedical services. For Assistance Contact CCWRO at 916-712-0071 or email [email protected] OPTIONAL: If you want help with this please sign below. Thank You I hereby authorize Kevin Aslanian to be my authorized representative. Date Your Signature ”

pdf IHSS – CCWRO IHSS Protective Supervision Hazard Log Form

In IHSS

” IHSS Protective Supervision Hazard\/Injury Log Name of IHSS recipient\/applicant _____________________________ Case Number ____________________ Risk of Injury or Harm Activities Would this happen if you were not watching this person 7 days a week, 24- hour a day? Would they do: Dates of Occurrence if this has happened? Comments Wandering out of the house and getting lost Yes No Letting strangers in the house Yes No Turning the stove on and forgetting to turn it off Yes No Starting fires in the microwave Yes No Lighting small fires around the home Yes No Leaving water running Yes No Eating dangerous products or unhealthy foods, like soap or laundry detergent Yes No Eating inappropriate food for medical condition. For example: drinking unlimited soda when a person has diabetes Yes No Head banging, self-biting and scratching Yes No Using knives or other unsafe household objects Yes No Climbing onto a high place and jumping off because he or she is trying to fly Yes No Hiding in the refrigerator Yes No Sticking items in light socket or electrical outlet Yes No Sticking hands in dirty toilet Yes No Wandering into the street without regard for oncoming traffic Yes No Jumping into a swimming pool without knowing how to swim Yes No Trying to move furniture when the individual lacks needed balance and strength Yes No Using a SOS pads or non-cloth scrubbers to bathe and clean himself or herself Yes No Trying to walk when it is unsafe to walk unassisted Yes No Hiding dirty diapers Yes No Playing with feces Yes No Hitting mirrors or television Yes No Standing\/sitting on glass table Yes No DECLARATION I am a resident of ___________________________ County, State of California and I declare under the penalty of perjury that the information provided above is true and correct. SIGNATURE OF DECLARANT: NAME OF DECLARANT DATE: ADDRESS: CITY\/ZIP TELEPHONE: ( ) DOCTOR CERTIFICATION I certify that I am licensed to practice in the State of California and that the information provided above is correct. SIGNATURE OF PHYSICIAN OR MEDICAL PROFESSIONAL: MEDICAL SPECIALTY: DATE: ADDRESS: LICENSE NO.: TELEPHONE: ( ) Name ofIHSSrecipientapplicant: Case Number: RiskofInjuryor Harm Activities: Dates of Occurrence if this has happenedYes No: CommentsYes No: Dates of Occurrence if this has happenedYes No_2: CommentsYes No_2: Dates of Occurrence if this has happenedYes No_3: CommentsYes No_3: CommentsYes No_4: Dates of Occurrence if this has happenedYes No_5: CommentsYes No_5: Dates of Occurrence if this has happenedYes No_6: CommentsYes No_6: Dates of Occurrence if this has happenedYes No_7: CommentsYes No_7: Dates of Occurrence if this has happenedYes No_8: CommentsYes No_8: Dates of Occurrence if this has happenedYes No_9: CommentsYes No_9: Dates of Occurrence if this has happenedYes No_10: CommentsYes No_10: Dates of Occurrence if this has happenedYes No_11: CommentsYes No_11: Dates of Occurrence if this has happenedYes No_12: CommentsYes No_12: Dates of Occurrence if this has happenedYes No_13: CommentsYes No_13: Dates of Occurrence if this has happenedYes No_14: CommentsYes No_14: Yes No: Yes No_2: Yes No_3: Yes No_4: Yes No_5: Hidingdirty diapers: Yes No_6: Playingwithfeces: Yes No_7: Yes No_8: Yes No_9: above is true and correct: SIGNATURE OF DECLARANT: NAME OF DECLARANT: DATE: ADDRESS: CITYZIP: TELEPHONE: SIGNATURE OF PHYSICIAN OR MEDICAL PROFESSIONAL: MEDICAL SPECIALTY: DATE_2: ADDRESS_2: LICENSE NO: TELEPHONE_2: Check Box1: Off Check Box2: Off Check Box4: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box21: Off Check Box22: Off Check Box23: Off Check Box24: Off Check Box31: Off Check Box32: Off Check Box3: Off Check Box33: Off Check Box34: Off Check Box35: Off Check Box36: Off Check Box37: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box43: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box48: Off Check Box49: Off Check Box50: Off Check Box1[pin: Off oi64waw: Off ”

pdf IHSS – CCWRO "Request for IHSS Reassessment" form -6-18

In IHSS

” REQUEST FOR IHSS REASSESSMENT TO: County of _______________________ Name of Social Worker: ______________________________________ IHSS Case # _______________________________________ I, ____________________________________________________________ Name of IHSS Recipient request a reassessment because my needs for services has changed and I need more hours. Thank you for your consideration of my request for reassessment. Dated:_________ ___________________________________________ Signature of IHSS Recipient\/Representative FORM INSTRUCTION: This form should be mailed to the IHSS recipient’s social worker anytime the IHSS recipient believes that he or she has a change and in needs more hours. If the county does not act on this request within 30 days file for a state hearing at: https:\/\/secure.dss.cahwnet.gov\/shd\/pubintake\/cdss- request.aspx IHSS State Regulation Number 30-761.219 The county shall reassess the recipient’s need for services: (a) Any time the recipient notifies the county of a need to adjust the service hours authorized due to a change in circumstances; or (b) When there is other pertinent information which indicates a change in circumstances affecting the recipient’s need for supportive services. For Assistance contact CCWRO at 916-712-0071 or email [email protected] Additional Areas of Services Requested Type of Service Current hours per week Hours requested per week Rank Reason for request Domestic Services Respiration Bowel\/bladder care Feeding Be bath Dressing Min. Care Ambulation Transfer Bathing Medical Appointment Protective superviusion TOCountyof: Name ofSocialWorker: undefined: I: Dated: undefined_2: Current hours per weekDomest i c Services: Hours requested per weekDomest i c Services: RankDomest i c Services: Reason for requestDomest i c Services: Current hours per weekResp i rat i on: Hours requested per weekResp i rat i on: RankResp i rat i on: Reason for requestResp i rat i on: Reason for requestBowe l b l adder care: Current hours per weekFeed i ng: Hours requested per weekFeed i ng: RankFeed i ng: Reason for requestFeed i ng: Current hours per weekBe bath: Hours requested per weekBe bath: RankBe bath: Reason for requestBe bath: Current hours per weekDress i ng: Hours requested per weekDress i ng: RankDress i ng: Reason for requestDress i ng: Current hours per weekMin Care: Hours requested per weekMin Care: RankMin Care: Reason for requestMin Care: Current hours per weekAmbu l at i on: Hours requested per weekAmbu l at i on: RankAmbu l at i on: Reason for requestAmbu l at i on: Current hours per weekTransfer: Hours requested per weekTransfer: RankTransfer: Reason for requestTransfer: Current hours per weekBath i ng: Hours requested per weekBath i ng: RankBath i ng: Reason for requestBath i ng: Reason for requestMed i ca l Appo i ntment: Reason for requestProtect i ve superviusion: adder: adder1: adder2: ntment: ntment1: ntment2: superviusion: superviusion1: superviusion2: ”

pdf IHSS – 2018 IHSS ranking form for IHSS applicants and recipients

In IHSS

” IHSS Ranking Evaluation Patient’s Name SSN DOB Date Patient last seen: Duration of the needs indicated below __3-month __6 months __ 1 year __ Indefinite Please check the level of assistance needed 1. Preparation of meals 2. Meal Clean- up 3. Feeding 4. Bed Baths 5. Bathing, Oral Hygiene 6. Dressing 7, Bowell & Bladder Care 8. Reposition 9. Skin Care 10. Transferring from Bed 11. Ambulation None Able to perform the function, but needs verbal assistance, such a reminding, guidance. Can perform the function with some human assis- tance including physical help for a provider. Can perform the function but only with substantial human assistance. Cannot perform the function with or without human assistance. CERTIFICATION – I certify that I am licensed to practice in the State of California and that all information above is true and correct. Physician Signature MD Provide # Date IHSS Ranking Evaluation: SSN: DOB: Date Patient last seen: California and that all information above is true and correct: 11 Ambulation: Check Box1: Off Check Box3: Off Check Box4: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box15: Off Check Box16: Off Check Box134t: Off Check Box1 this: Off Check Box19: Off Check Box111: Off Check Box1112: Off Check Box20: Off Check Box21: Off Check Box22: Off Check Box23: Off Check Box25: Off Check Box26: Off Check Box27: Off Check Box29: Off Check Box1209k: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box36: Off Check Box37: Off Check Box=38: Off Check Box39: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box50: Off Check Box51: Off Check Box52: Off Check Box54: Off Check Box55: Off Check Box57: Off Check Box58: Off Check Box1 year: Off =2 yer: Off 3 yer: Off lb jbjk: Off pg9pgyu80y: Off 9-]-0tf: Off Check B’o;ugv;b: Off ‘bobjlklm: Off Check Box56nlkn: Off Check Box56 kl\/’ioih: Off ”

pdf IHSS – 2018 IHSS ranking form for child IHSS applicants or recipients

In IHSS

” IHSS Child Ranking Evaluation Patient’s Name SSN DOB Date Patient last seen: Duration of the needs indicated below __3-month __6 months __ 1 year __ Indefinite Please check the level of assistance needed 2. Feeding 3. Bed Baths 1. Bathing, Oral Hygiene 5. Dressing 4. Bowel & Bladder Care 6. Reposition 7 Skin Care 9. Transferring from Bed 8. Ambulation None Able to perform the function, but needs verbal assistance, such a reminding, guidance. Can perform the function with some human assis- tance including physical help for a provider. Can perform the function but only with substantial human assistance. Cannot perform the function with or without human assistance. Other children of the same age do not routinely need this service. CERTIFICATION – I certify that I am licensed to practice in the State of California and that all information above is true and correct. Physician Signature MD Provide # Date CCWRO 2018-11-IHSS IHSS Ranking Evaluation: SSN: DOB: Date Patient last seen: 9 Skin Care: California and that all information above is true and correct: Check Box1: Off Check Box3: Off Check Box4: Off Check Box5: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off Check Box12: Off Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Check Box25: Off Check Box2: Off Check Box27: Off Check Box28: Off Check Box29: Off Check Box30: Off Check Box31: Off Check Box32: Off Check Box33: Off Check Box34: Off Check Box35: Off Check Box36: Off Check Box37: Off Check Box38: Off Check Box39: Off Check Box40: Off Check Box41: Off Check Box42: Off Check Box43: Off Check Box44: Off Check Box45: Off Check Box46: Off Check Box47: Off Check Box48: Off Check Box49: Off Check Box50: Off Check Box51: Off Check Box52: Off Check Box53: Off Check Box54: Yes Check Box55: Yes Check Box56: Off Check Box57: Off Check Box58: Off Check Box59: Off Check Box60: Yes Check Box61: Yes Check Box6: Off Check Box68: Off Check Box681: Off Check Box683: Off Check Box68′;kn’kn: Off ”

pdf CCWRO IHSS Reassessment Request Form (12-1-13)

In IHSS

” REQUEST FOR IHSS REASSESSMENT TO: County of _______________________ Name of Social Worker: ______________________________________ IHSS Case # _______________________________________ I, ____________________________________________________________ Name of IHSS Recipient request a reassessment because my needs for services has changed and I need more hours. Thank you for your consideration of my request for reassessment. Dated:__________ ___________________________________________ Signature of IHSS Recipient\/Representative FORM INSTRUCTION: This form should be mailed to the IHSS recipient’s social worker anytime the IHSS recipient believes that he or she has a change and in needs more hours. If the county does not act on this request within 30 days file for a state hearing at: https:\/\/secure.dss.cahwnet.gov\/shd\/pubintake\/cdss- request.aspx IHSS State Regulation Number 30-761.219 The county shall reassess the recipient’s need for services: (a) Any time the recipient notifies the county of a need to adjust the service hours authorized due to a change in circumstances; or (b) When there is other pertinent information which indicates a change in circumstances affecting the recipient’s need for supportive services. For Assistance contact CCWRO at 916-712-0071 or email [email protected] www.ccwro.org TO County of: Name of Social Worker: undefined: I: Dated: ”

Medi-Cal 250% Program

pdf Medi-Cal 250% employment verification form (3-2020)

In Medi-Cal 250% Program

” Medi-Cal 250% Program Employment Verification This is to confirm that Name of Medi-Cal beneficiary SSN has been working for me commencing with and each month thereafter for date hours each week for $ a week for a total monthly sum of $ a month doing the following work for me: ________________________________ Specify type of work being done EMPLOYER NAME: ___ EMPLOYER ADDRESS: _____ DATE: ___________ EMPLOYER SIGNATURE: _________________________ Authorization to Release Information\/Representation Form I, , hereby authorize the person\/organization named herein, or any other person\/attorney designated them to be my authorized representative, and to represent me, relative to my Medi-Cal benefits, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to any person designated by him, including an attorney. Dated: ___________________ ________________________________________ Signature of Medi-Cal Recipient\/Applicant Authorized Representative Name of Person and\/Organization Name Organization, if any Address Phone Number This is to confirm that: SSN 1: undefined: hours each week for: undefined_2: I: Name: Organization if any: Dated: Ca: Rec: entApp: cant: Address: Phone NumberRow1: SSN 2: SSN 24: 5: SSN 23r: ”

pdf Medi Cal 250% Income Verficition form -11-2020

In Medi-Cal 250% Program

” Medi-Cal 250% Program Employment Verification Form I, ____________________________________________________ the employer of the Medi-Cal beneficiary named_______________________________________________ Address_______________________________ City ______________ ZIP___ Case #\/SSN ________________ has been working for me since _____________ and each and every month thereafter and hereinafter for ____ hour a week, for a total compensation of $_____ a month performing the following work for me: EMPLOYER INFORMATION Employer name _________________________________________________________ Employer address _______________________________________________________ Date__________ Employer Signature _______________________________________ AUTHORIZATION RELEASE INFORMATION\/REPRESENTATION FORM I, ____________________________________________named below, or any other person\/attorney designated them to be my authorized representative, and to represent me, relative to my Medi—Cal benefits, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to any person designated by the person mentioned below, including an attorney. Date: _______________ ___________________________________ _ Signature of Employee\/Medi-Cal Beneficiary Name of person\/organization being authorized Kevin Aslanian CCWRO, 1111 Howe Ave., Suite 635, Sacramento, CA 95825-8551 Tel. 916-712-0071 Email: [email protected] CCWRO 250% MC Work Verification Form 11-2020 Address: City: ZIP: Case SSN: has been working for me since: and every month thereafter and hereinafter for: undefined: a month performing the following work for me: Employer address: Date: Date_2: I: MediCal beneficiary named: ”

Welfare To Work

pdf ]WtW fornm – CCWRO CalWORKs WtW Support Services Advance Payment Request(7-17)

In Welfare To Work

” Name of WtW Participant: Case # of WtW Participant: Phone Number of Participant: Email Address of Participant: I, the undersigned, hereby request advance pay for transportation and\/or ancillary services, otherwise I will be forced to use my CalWORKs fixed income which is at the same level that a CalWORKs recipient received in 1985, to pay for the costs of transportation and ancillary services in order to participate in my assigned WtW activity. Using my CalWORKs limited money for transportation and ancillary services would be detrimental to my family. Your assistance to assure that I am not forced to use my CalWORKs money for WtW transportation and ancillary services is greatly appreciated. Request for Advance Payment of: Transportation (Please explain) __________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ WtW Request for Advance Pay Per MPP 42-750.21 Ancillary Services, like books, uniforms, tools, ect. (Please explain) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I want representation by the following person I also hereby authorize Name of Person, Organization if any to be my authorized representative in this matter or any other matter relative to my social services case and hereby authorize the county human services agency to release any and all information to her\/him at her\/his request. I further authorize her\/him to request a state hearing on my behalf, including initiating litigation to assure that my rights are protected and enforced. Date: Signature of WtW Supportive Services Advance Payment Regulations MPP 42-750 .21 Payments for supportive services, except child care as described in Chapter 47-100, shall be advanced to the participant when necessary and desired by the participant so that the participant need not use personal funds to pay for these services. WHAT TO DO IF THE COUNTY WON’T COMPLY? If your county is not complying with the law you can email a complaint to the following email addresses: [email protected] INTRUCTION FOR COMPLETING WtW ADVANCE PAYMENT OF SUPPORTIVE SERVICES FORM I. Complete the name of the Participant; 1. The case number that can be found on the various forms that the CalWORKs recipient has, including WtW forms. 2. The phone number of the participant. 3. The email address of the participant. 4. Explain transportation. If it takes more than an hour from your house to the place to your WtW activity, then you are entitled to mileage. The one hour each way includes necessary walking time. 5. For ancillary services put down what you need, how much it costs, and verification that it is needed. If you have any questions, call Kevin Aslanian at 916-712-0071. III. WHAT TO DO AFTER COMPLETING THIS FORM 1. Take this form down to the county welfare office and turn it into the receptionist and make sure to get a receipt. You can also email this form after scanning them and turning them into pdf forms. Email it to the worker, supervisor, county welfare director, deputy director. Your can find the email addresses of the county welfare director at: https:\/\/www.cwda.org\/membership 2. If you do not have the email address of the worker, you can still 2. If within a reasonable time, like 10-20 days you should ask for a state fair hearing. You can find a form called CCWRO Fair Hearing Filllible Request form -09-2011 to request a hearing at: http:\/\/www.ccwro.org\/index.php?opti on=com_docman&Itemid=70 3. You can designate CCWRO as the authorized representative. 4. You can fax the hearing request to 916-651-5210, which is the fax number for the State Department of Social Services. 5.If you want CCWRO to represent you, you should fax a copy of the hearing request to 916-736-2645. FOR ANY ASSISTANCE CONTACT CCWRO at: http:\/\/ccwro.org Or call 916-712-0071 and ask for Kevin Aslanian mailto:[email protected] https:\/\/www.cwda.org\/membership http:\/\/www.ccwro.org\/index.php?opti http:\/\/ccwro.org\/ Name of WtW Participant: Case of WtW Participant: Phone Number of Participant: Email Address of Participant: Transportation Please explain 1: Transportation Please explain 2: Transportation Please explain 3: Transportation Please explain 4: Transportation Please explain 5: Transportation Please explain 6: Transportation Please explain 7: Transportation Please explain 8: Transportation Please explain 9: Transportation Please explain 10: Transportation Please explain 11: explain 1: explain 2: explain 3: explain 4: explain 5: explain 6: explain 7: I want representation by the following person: assure that my rights are protected and enforced: undefined: ”

pdf WtW Sanction Cure Request Form During the Coronavirus Pandemic- 10-2020

In Welfare To Work

” 1 REQUEST TO MEET WELFARE-TO-WORK RULES TO GET MY CASH AID BACK PER ACWDL 3-13-20, 3-30-20 & 6-29-20 HOW TO GET MORE Cash Aid during the coronavirus pandemic: Your family gets less cash aid because you did not meet Welfare-to-Work rules. If you want your cash aid back, you can fill out this form and return it to your Welfare-to-Work worker right away. REQUEST TO MEET WELFARE-TO-WORK RULES TO GET MY CASH AID BACK I agree to participate in the WtW program when the county asks me to do so. I understand that during the coronavirus pandemic I will not be asked to participate. After the pandemic, if asked to participate, I will need help with: __ Child Care __ Transportation __ Other NAME (PLEASE PRINT): SIGNATURE: CASE # OR SOCIAL SECURITY #: PHONE #: ( ) DATE: WELFARE-TO-WORK WORKER’S NAME (PLEASE PRINT): BIRTHDATE YOUR EMAIL ADDRESS DO YOU NEED FREE LEGAL HELP? Coalition of California Welfare Rights Organizations (CCWRO) 1111 Howe Ave., Suite 635, Sacramento, CA 95825 Telephone (916) 712-0061 ccwro.org HOW TO USE THIS FORM? You can give this to your worker. You can mail us this form and we will give it to your worker if you authorize us to do so. If you want us to help you, you have to sign below authorizing us to help you. I, the undersigned authorize CCWRO and any person working with them to be my authorized representative for all purposes, including filing for a state hearing: Date___________ Your Signature______________________________________________________ NAME PLEASE PRINT: CASE OR SOCIAL SECURITY: PHONE: DATE: Date: Check Box1: Off Check Box3: Off Check Box2io0: Off birthdate: BIRTHDATE YOUR EMAIL ADDRESS: WTW WORKER: ”

pdf WtW Advance Payment Request form for Books and Transportaton payment

In Welfare To Work

” Name of WtW Participant: Case # of WtW Participant: Phone Number of Participant: Email Address of Participant: I, the undersigned, hereby request advance pay for transportation and\/or ancillary services, otherwise I will be forced to use my CalWORKs fixed income which is at the same level that a CalWORKs recipient received in 1985, to pay for the costs of transportation and ancillary services in order to participate in my assigned WtW activity. Using my CalWORKs limited money for transportation and ancillary services would be detrimental to my family. Your assistance to assure that I am not forced to use my CalWORKs money for WtW transportation and ancillary services is greatly appreciated. Request for Advance Payment of: Transportation (Please explain) __________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ WtW Request for Advance Pay Per MPP 42-750.21 Ancillary Services, like books, uniforms, tools, ect. (Please explain) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I want representation by the following person I also hereby authorize Name of Person, Organization if any to be my authorized representative in this matter or any other matter relative to my social services case and hereby authorize the county human services agency to release any and all information to her\/him at her\/his request. I further authorize her\/him to request a state hearing on my behalf, including initiating litigation to assure that my rights are protected and enforced. Date: Signature of WtW Supportive Services Advance Payment Regulations MPP 42-750 .21 Payments for supportive services, except child care as described in Chapter 47-100, shall be advanced to the participant when necessary and desired by the participant so that the participant need not use personal funds to pay for these services. WHAT TO DO IF THE COUNTY WON’T COMPLY? If your county is not complying with the law you can email a complaint to the following email addresses: [email protected] INTRUCTION FOR COMPLETING WtW ADVANCE PAYMENT OF SUPPORTIVE SERVICES FORM I. Complete the name of the Participant; 1. The case number that can be found on the various forms that the CalWORKs recipient has, including WtW forms. 2. The phone number of the participant. 3. The email address of the participant. 4. Explain transportation. If it takes more than an hour from your house to the place to your WtW activity, then you are entitled to mileage. The one hour each way includes necessary walking time. 5. For ancillary services put down what you need, how much it costs, and verification that it is needed. If you have any questions, call Kevin Aslanian at 916-712-0071. III. WHAT TO DO AFTER COMPLETING THIS FORM 1. Take this form down to the county welfare office and turn it into the receptionist and make sure to get a receipt. You can also email this form after scanning them and turning them into pdf forms. Email it to the worker, supervisor, county welfare director, deputy director. Your can find the email addresses of the county welfare director at: https:\/\/www.cwda.org\/membership 2. If you do not have the email address of the worker, you can still email them to the director and other 2. If within a reasonable time, like 10-20 days you should ask for a state fair hearing. You can find a form called CCWRO Fair Hearing Filllible Request form -09-2011 to request a hearing at: http:\/\/www.ccwro.org\/index.php?opti on=com_docman&Itemid=70 3. You can designate CCWRO as the authorized representative. 4. You can fax the hearing request to 916-651-5210, which is the fax number for the State Department of Social Services. 5. If you want CCWRO to represent you, you should fax a copy of the hearing request to 916-736-2645. FOR ANY ASSISTANCE CONTACT CCWRO at: http:\/\/ccwro.org Or call 916-712-0071 and ask for Kevin Aslanian Name of WtW Participant: Case of WtW Participant: Phone Number of Participant: Email Address of Participant: Transportation Please explain 1: Transportation Please explain 2: 1: 2: 3: 4: 5: 6: 7: 8: 9: explain 1: explain 2: explain 3: explain 4: explain 5: explain 6: explain 7: I want representation by the following person: assure that my rights are protected and enforced: undefined: ”

pdf CalWORKs WtW – CCWRO WtW Volunteer to Participate form

In Welfare To Work

” Volunteer Application to Participate in WtW Name of WtW Volunteer __________________________ Case Number of WtW Volunteer __________________________ Address of WtW Volunteer __________________________ Telephone of WtW Volunteer __________________________ Email address of WtW Volunteer __________________________ County Worker Name __________________________ I, the undersigned, hereby request that I be approved to participate in a WtW activity. Attached is information about what I want to volunteer for. Please provide me with a decision via an adequate notice of action within 10 days that is the same number of days the county gives CalWORKs recipients to provide verification. Thanks you for your assistance in this matter. Dated: __________________________________ Signature of Volunteer WtW Regulations 42-701(v)(1) \”Volunteer\” means a CalWORKs applicant or recipient who, though not required to participate in the Welfare-to-Work Program, chooses to participate. 42-712 .5 Any individual who is not required to participate may volunteer to participate in welfare-to- work activities and may end that participation at any time without loss of eligibility for aid, provided his or her status has not changed in a way that requires participation. .51 For purposes of Section 42-715.5, a volunteer participant is as follows: .511 An individual who is exempt pursuant to Sections 42-712.41 through .49, but who volunteers to participate; or .512 An individual who is not required to participate for reasons other than the exemptions described in Sections 42-712.41 through .49, but who volunteers to participate. Participate in WtW: Case Number of WtW Volunteer 1: Case Number of WtW Volunteer 2: Case Number of WtW Volunteer 3: Email address of WtW Volunteer 1: Email address of WtW Volunteer 2: ”

CalFresh and CalWORKs

pdf SB 1232 College Book Payment Request for Costs That Exceed the Standard Payment

In CalFresh and CalWORKs

” College Book Payment Request for CostsThat Exceed the Standard Payment Student’s Name _________________________________________ Case # Name of College: The books listed are below are required for the classes that I have enrolled in. Class # Course name Books\/Materials Tax Included Amount Yes No Yes No Yes No Yes No Yes No Please attach the syllabus for each class Mandatory fees\/costs, such as school supplies, uniforms, other items required for the classes you are taking Mandatory fees\/costs, such as school supplies, uniforms, other items required for the classes you are taking Class\/Course Name Amount I hereby authorize CCWRO to be my authorized representative. Signature of CalWORKs Recipient Date Welfare & Institutions Code 11321(c) A recipient may request reimbursement for the actual costs for the purpose of paying costs associated with attending the postsecondary educational institution pursuant to Section 11323.2 if the recipient provides verification of expenses that exceed the applicable amount set forth in subdivision (a) for books and college supplies that are required for the classes in which the individual is enrolled. The county shall issue payment within 20 days of the recipient’s request. ACL 22-31- If expenses for necessary books and supplies for courses enrolled in exceed the advance standard payment provided, clients should request reimbursement or advance payment for actual ancillary supportive service expenses as highlighted in Question and Answer #25 of ACL 21-75E. Clients may only receive reimbursement for required and\/or necessary materials for classes in which they are enrolled that have been verified to exceed the advance standard payment amount. CCWRO- Coalition of California Welfare Rights Organizations, Inc. 1111 Howe Ave., Suite 635 Sacramento, CA 95825, Tel. 9146-712-0071 email [email protected] https:\/\/cdss.ca.gov\/Portals\/9\/Additional-Resources\/Letters-and-Notices\/ACLs\/2021\/21-75E.pdf mailto:[email protected] Exceed the Standard Payment: Name of College: Tax Included: Class Row1: Course nameRow1: BooksMaterialsRow1: undefined: Off AmountYes No: Class Row2: Course nameRow2: BooksMaterialsRow2: undefined_2: Off AmountYes No_2: Class Row3: Course nameRow3: BooksMaterialsRow3: undefined_3: Off AmountYes No_3: Class Row4: Course nameRow4: BooksMaterialsRow4: undefined_4: Off AmountYes No_4: Class Row5: Course nameRow5: BooksMaterialsRow5: undefined_5: Off AmountYes No_5: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow1: ClassCourse NameRow1: AmountRow1: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow2: ClassCourse NameRow2: AmountRow2: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow3: ClassCourse NameRow3: AmountRow3: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow4: ClassCourse NameRow4: AmountRow4: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow5: ClassCourse NameRow5: AmountRow5: Mandatory feescosts such as school supplies uniforms other items required for the classes you are takingRow6: ClassCourse NameRow6: AmountRow6: I hereby authorize CCWRO to be my authorized representative: Off Signature of CalWORKs Recipient: Date: Case: Check Box4: Off Check Box5: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box12: Off Check Box13: Off 15: Off 23t5g: Off Check Box7y7535h: Off Check Box1kefon: Off ”

pdf CalWORKs Stage 1 Child Care Request Form – 2020

In CalFresh and CalWORKs

” CALWORKS CHILD CARE REQUEST I to want childcare for my child or children now? __ Yes __No You are eligible for full-time childcare (30 or more hours per week) or part time, less than 30 hours a week. Do you want __ Full Time __ Part Time Will you need childcare if you start working, going to school, training, job search, counseling, housing search, or any other reason? __ Yes __No Your Name Case No. Your Signature Date Address Phone INSTRUCTIONS: Complete this form and mail or email it to your worker. You can also upload it to you on-line account. WHAT HAPPENS IF I DO NOT HEAR ANYTHING FROM THE COUNTY OR MY WORKER? If you do not hear anything within 10 days, you can ask for a state hearing by going to: https:\/\/acms.dss.ca.gov\/acms\/page.request.do?page=public.intak eForm HOW DO I GET HELP WITH THE HEARIONG? You can contact CCWRO at 916-736-0616 to get help with a hearing to get you childcare. Even if you don’t need childcare now, you can ask for childcare at any time. Your Name: Case No: Your Signature: Date: Address: Phone: Check Box1: Off Check Box1=2: Off Check Box3: Off Check Box4: Off Check Box5: Off Check Box6: Off ”

pdf CalWORKs Form – 2018 CalWORKs Clock Stoppers Check List

In CalFresh and CalWORKs

” CalWORKs WtW Exemptions Age 60 or Older (MPP 42.302.21(e) & 42\u00b7712.43) Aid reimbursed child support 42-302.21(g) Aided Nonparent Relative Caring for a Child Who is a Dependent or Ward of the Court, a child who is Receiving Kin-GAP Benefits or a Child at Risk of Placement in Foster Care (MPP 42-302.21(b)(2) & 42-712.45) An individual is exempt If he\/she is a full-time volunteer in the Volunteers In Service America (VISTA) program 42- 712.49 Care of a Child 6 Months or Under (MPP Section 42- 712.47) Care of an Ill or Incapacitated Member of the Household (MPP 42-302.21(b) & 42-712.46 Caring for a child 0-23 months of age (WIC code section 11320.3) Clients exempt as of 12\/31\/2012 for a short-term exemption based on personally providing care for one child between 12 and 23 months or two children under age six which expires on January 1, 2015 (WIC code section 11320.3(h)(1) Domestic Abuse Waiver (MPP Sections 42-302.219(c) & 42-715.5) Disability (MPP Sections 42-712.44 & 42-302.111 & 21e) Eligible for, participating in, or exempt from the Cal-Learn program or another approved teen parent program when receiving aid in their parents AU or in their own AU, (MPP Sections 42-302.21(d) & 41-712.11) Good cause for not participating (MPP Section 42-713) Grant Amounts $10 Or Less (MPP Section 42-302.21(f) Pregnancy (MPP Section 42-712.48) School Attendance for individuals age 16,17, or 18 years of age (MPP Section 42-712.42) CalWORKs 24-Month Clock Stopper 24- month Stopper Age 60 or Older (MPP 42.302.21(e) & 42\u00b7712.43) Aided Nonparent Relative Caring for a Child Who is a Dependent or Ward of the Court, a child who is Receiving Kin-GAP Benefits or a Child at Risk of Placement in Foster Care (MPP 42-302.21(b)(2) & 42-712.45) An individual is exempt If he\/she is a full-time volunteer in the Volunteers In Service America (VISTA) program 42- 712.49 Care of a Child 6 Months or Under (MPP Section 42- 712.47) Care of an Ill or Incapacitated Member of the Household (MPP 42-302.21(b) & 42-712.46 Caring for a child 0-23 months of age (WIC code section 11320.3) Clients exempt as of 12\/31\/2012 for a short-term exemption based on personally providing care for one child between 12 and 23 months or two children under age six which expires on January 1, 2015 (WIC code section 11320.3(h)(1) Clients in sanction status (WIC code section 11322.85) Clients meeting Federal WPR requirements (WIC code section 11322.85(b)(2)) Domestic Abuse Waiver (MPP Sections 42-302.219(c) & 42-715.5) Disability (MPP Sections 42-712.44 & 42-302.111 & 21e) Eligible for, participating in, or exempt from the Cal-Learn program or another approved teen parent program when receiving aid in their parents AU or in their own AU, (MPP Sections 42-302.21(d) & 41-712.11) Good cause for not participating (MPP Section 42-713) Pregnancy (MPP Section 42-712.48) School Attendance for individuals age 16,17, or 18 years of age (MPP Section 42-712.42) CalWORKs 48-month Clock Stopper 48- month stopper AB 12 recipients (MPP 42-302.21b, 42-712.45 & 42-30 2.112(a) Age 60 or Older (MPP 42.302.21(e) & 42\u00b7712.43) Aid reimbursed child support 42-302.21(g) Aided Nonparent Relative Caring for a Child Who is a Dependent or Ward of the Court, a child who is Receiving Kin-GAP Benefits or a Child at Risk of Placement in Foster Care (MPP 42-302.21(b)(2) & 42-712.45) Care of a Child 6 Months or Under (MPP Section 42- 712.47) Care of an Ill or Incapacitated Member of the Household (MPP 42-302.21(b) & 42-712.46 Caring for a child 0-23 months of age (WIC code section 11320.3) Clients exempt as of 12\/31\/2012 for a short-term exemption based on personally providing care for one child between 12 and 23 months or two children under age six which expires on January 1, 2015 (WIC code section 11320.3(h)(1) Clients in sanction status (WIC code section 11322.85) Clients meeting Federal WPR requirements (WIC code section 11322.85(b)(2)) Domestic Abuse Waiver (MPP Sections 42-302.219(c) & 42-715.5) Disability (MPP Sections 42-712.44 & 42-302.111 & 21e) Eligible for, participating in, or exempt from the Cal-Learn program or another approved teen parent program when receiving aid in their parents AU or in their own AU, (MPP Sections 42-302.21(d) & 41-712.11) Grant Amounts $10 Or Less (MPP Section 42-302.21(f) Living in Indian County with a 50% unemployment rate (MPP Section 42-302.21(b) Unaided individual is out of AU for reasons other than exceeding time limits (i.e. no social security number) (MPP Sections 42-302.21f &42-302.115) CalWORKs Clock Stopper & WtW Exemptions WtW Exemp 24- month Stopper 48- month stopper 60- month stopper AB 12 recipients (MPP 42-302.21b, 42-712.45 & 42-30 2.112(a) N\/A N\/A X Age 60 or Older (MPP 42.302.21(e) & 42\u00b7712.43) X X X Aid reimbursed child support 42-302.21(g) X Aided Nonparent Relative Caring for a Child Who is a Dependent or Ward of the Court, a child who is Receiving Kin-GAP Benefits or a Child at Risk of Placement in Foster Care (MPP 42-302.21(b)(2) & 42-712.45) X X X An individual is exempt If he\/she is a full-time volunteer in the Volunteers In Service America (VISTA) program 42-712.49 X X Care of a Child 6 Months or Under (MPP Section 42-712.47) X X X Care of an Ill or Incapacitated Member of the Household (MPP 42-302.21(b) & 42-712.46 X X X Caring for a child 0-23 months of age (WIC code section 11320.3) X X X Clients exempt as of 12\/31\/2012 for a short-term exemption based on personally providing care for one child between 12 and 23 months or two children under age six which expires on January 1, 2015 (WIC code section 11320.3(h)(1) X X X Clients in sanction status (WIC code section 11322.85) X X Clients meeting Federal WPR requirements (WIC code section 11322.85(b)(2)) X Domestic Abuse Waiver (MPP Sections 42-302.219(c) & 42- 715.5) X X X Disability (MPP Sections 42-712.44 & 42-302.111 & 21e) X X X Eligible for, participating in, or exempt from the Cal-Learn program or another approved teen parent program when receiving aid in their parents AU or in their own AU, (MPP Sections 42-302.21(d) & 41-712.11) X X X Good cause for not participating (MPP Section 42-713) X X Grant Amounts $10 Or Less (MPP Section 42-302.21(f) X Living in Indian County with a 50% unemployment rate (MPP Section 42-302.21(b) X X Pregnancy (MPP Section 42-712.48) X X School Attendance for individuals age 16,17, or 18 years of age (MPP Section 42-712.42) X X N\/A Unaided individual is out of AU for reasons other than exceeding time limits (i.e. no social security number) (MPP Sections 42- 302.21f &42-302.115) X Check Box1: Off Check Box2: Off Check Box3: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box11: Off Check Box13: Off Check Box14: Off Check Box165: Off Check Box17: Off Check Box18: Off Check Box111: Off Check Box112: Off Check Box114: Off Check Box11334f: Off Check Box123434: Off 17: Off 3rfj: Off 3fp]l;kmnv: Off 34rfed: Off 0-34mpk: Off 32m: Off 1f24npi: Off 34vkmd: Off 124ij0[i4[n: Off 2ij43nk: Off 2 ;v3=]fv: Off 40pi flm: Off 3-==[p3rklpvc: Off 2`413h9v3r: Off 0=24-=l,v: Off `3=1mrc: Off =-23fld: Off =12-4,fcd,: ,: Off 134=-lc: Off qwd;lm]1p23oj: Off Check Bo2e4=-lp]c: Off Check Box12`f: Off Check Box12: Off Check Box12p342: Off Check Box13e: ‘?>RCc: Off Check Box124m[okpm3kpn’3: Off Check Box1234`0k2 cexs\/c: C: Off ”

pdf CalWORKs Child Care Request form

In CalFresh and CalWORKs

” REQUEST FOR CHILD CARE PURSUANT TO ACL 19-99 I, ______________________________________________________________ Case number __________________________________________________ Am requesting childcare for the following children: Name Age Full-time Part-time Type of activity that I will be engaged in: Job Search Working Going to School Date__________ ___________________________________ Signature DESIGNATION OF AN AUTHORIZED REPRESENTATIVE FOR THE COUNTY TO RELEASE INFORMATION I further authorize _________________________ or any person designated by them to be my authorized representative and to release any and all information to them as they request. Date__________ ___________________________________ Signature Case number: NameRow1: AgeRow1: FulltimeRow1: Partt i meRow1: NameRow2: AgeRow2: FulltimeRow2: Partt i meRow2: NameRow3: AgeRow3: FulltimeRow3: Partt i meRow3: NameRow4: AgeRow4: FulltimeRow4: Partt i meRow4: NameRow5: AgeRow5: FulltimeRow5: Partt i meRow5: NameRow6: AgeRow6: FulltimeRow6: Partt i meRow6: NameRow7: AgeRow7: FulltimeRow7: Partt i meRow7: NameRow8: AgeRow8: FulltimeRow8: Partt i meRow8: NameRow9: AgeRow9: FulltimeRow9: Partt i meRow9: Date: Date_2: Check Box3: Off q3r: Off qp]l: Off I: ”

pdf CalWORKs – CW 2202W- DSS CalWORKs Policy Interpretation Form

In CalFresh and CalWORKs

” STATE OF CALIFORNIA \u2014HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CalWORKs PROGRAM REQUEST FOR POLICY INTERPRETATION PI # INSTRUCTIONS: Complete items 1 -\u00ad10 of the form. Use a separate form for each policy interpretation request. Retain a copy of the CW 2202W for your records and submit via email to [email protected]. 1. REQUESTOR NAME: 5. COUNTY: 2. PHONE NO: EMAIL: 6. SUBJECT: 3. REGULATION CITE(S): 7. REFERENCES: (ACLs\/ACINs, COURT CASES etc.) 4. DATE OF REQUEST: 8. DATE RESPONSE NEEDED: 9. QUESTION: (INCLUDE SCENARIO IF NEEDED FOR CLARITY): 10. REQUESTOR’S PROPOSED ANSWER: 11. STATE POLICY RESPONSE: ANALYST: APPROVING MANAGER: DATE: DATE: The policy expressed in this response is based on the unique set of facts presented and should not be presumed to apply to all other situations. DATE RESPONSE RELEASED: CW 2202W (9\/15) PI: 1 REQUESTOR NAME: 5 COUNTY: 2 PHONE NO EMAIL: 6 SUBJECT: 3 REGULATION CITES: 7 REFERENCES ACLsACINs COURT CASES etc: 4 DATE OF REQUEST: 8 DATE RESPONSE NEEDED: undefined: undefined_2: ANALYST: APPROVING MANAGER: DATE: DATE_2: DATE RESPONSE RELEASED: undefined_3: undefined_4: undefined_5: undefined_6: undefined_7: undefined_8: undefined_9: undefined_39: undefined_386: undefined_33: ”

pdf CalWORKs – CCWRO Domestic Violence Waiver Request Form

In CalFresh and CalWORKs

” 1. I, ____________________________ SSN ____ ___ ______ hereby request a domestic violence waiver for the following Cal- WORKs program requirements because it would unfairly penalize my family and me: 60 month time clock MFG rule Child Support Cooperation DV Caused Overpayments Allowing a SIP WtW Sanction Participation in WtW Requiring teens 16-17 to be in school. Other ______________ ______________________________ 2. The following are the types of domestic violence I have experienced from ________________________________________________. Name of person PLEASE MARK THE BOX THAT DESCRIBES YOUR SITATION AND WHEN IT HAPPENED My abuser: Threatened or attempted physi- cal or sexual abuse upon me and\/or my family. From _______to _____________. Committed physical acts that threaten to result in injury to me. From _______to _____________. Committed physical acts that actually resulted in injury to me. From _______to _____________. Sexually abused me. From _______to _____________. I was forced as the caretaker relative of a dependent child to en- gage in nonconsensual sexual acts or activities. From _______to _____________. Threatened to kill or harm people or property. From _______to _____________. DOMESTIC VIOLENCE WAIVER REQUEST Threatened to kidnap my kids or me. From _______to _____________. Threatened to commit suicide, stalked me. From _______to _____________. Repeatedly used degrading or coercive language against me. From _______to _____________. Controlled my access to food and sleep From _______to _____________. Controlled or withheld access to economic and social resources From _______to _____________. I was in a relationship where I got hit, punched, kicked or hurt. From _______to _____________. Arguments often end with the person mentioned above pushing, shoving or slapping me. From _______to _____________. The person mentioned above has used a fist or weapon to hurt or threaten me. From _______to _____________. The person mentioned above forced me to engage in sex that makes me uncomfortable. From _______to _____________. The person above would disre- gard my decisions regarding safe sex or contraceptives. From _______to _____________. The person named above calls me names or puts me down. From _______to _____________. When he gets angry, he throws things around and sometimes at me. From _______to _____________. He accuses me of having af- fairs. He checks up on me. From _______to _____________. I have to ask for his permission to do things I want to do. From _______to _____________. I declare under penalty of perjury that he above statement is true and correct. Executed on _________________, _____ , in the City of _________________ State of California. BY_____________________________________ Authorization of Release and Representation Form I, __________________________, SSN _______________ hereby authorize the person designed below, or any other person\/attorney designated such person(s), to be my authorized representative, and to represent me, relative to my public social services matter, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to the person(s) designed below or any person designated by them, including an attorney. I further authorize the person(s) below or any other persons designated by them to apply for and represent me during all aspects of the application process or any other matter relative to the process of eligibility determination for any and all benefits that I and\/or my family may be eligible for. PERSON AND\/OR ORGANIZATION DESIGNED Name: __________________________________________________________ Name:___________________________________________________________ Organization:_____________________________________________________ Address:_________________________________________________________ Telephone:_______________________________________________________ Dated: ____________ Signature __________________________________ CCWRO DV questionaire 8-07 AR form for DV Check Box19: Off Check Box18: Off Check Box17: Off Check Box16: Off Check Box15: Off Check Box14: Off Check Box13: Off Check Box12: Off Check Box11: Off Check Box2: Off Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Text48: Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Check Box21: Off Check Box22: Off Check Box23: Off Check Box24: Off Check Box25: Off Check Box26: Off Check Box27: Off Check Box28: Off Check Box29: Off Check Box201: Off Check Box202: Off Check Box31: Off Check Box33: Off Check Box205: Off Check Box206: Off Check Box207: Off Check Box208: Off Check Box2434: Off Check Box234: Off ”

pdf CalWORKs – CCWRO CalWORKs disability medical verification form

In CalFresh and CalWORKs

” CalWORKs Ability to Perform Work or Training Medical conditions of ____________________________ ________________ that impedes patient’s ability to work. Name of patient SSN 1. Does the patient have a limitation that significantly affects the patients’ ability to be regularly employed or participate in training program o 20-hours o 30-hours o 35-hours a week? Yes o No o 2. What date did this condition first prevent your patient from working or training o 20-hours o 30-hours o 35-hours a week? hours a week? ___________________(date). If there were breaks, please specify months and years Month Year Month Year From _____ ______ to _____ _____ _____ ______ to _____ _____ _____ ______ to _____ _____ _____ ______ to _____ _____ _____ ______ to _____ _____ 3. Is this condition(s) expected to last more than 30 days? Yes o No o If yes , anticipated date when the Patient could perform o 20-hours o 30-hours o 35- hours a week off work or training: _____________. Date 4. Is there an appropriate medical treatment available? Yes o No o 5. Is the patient actively seeking treatment? Yes o No o ____________________________ _____________________ ____________________ Doctor Name Doctor Signature Title, license or certification _____________________________ ______________________________ Doctor’s Address Doctor’s Phone number & email thatimpedes patients ability to work: Abilityto Perform Workor Training: Name ofpatient: undefined: undefined_2: SSN: undefined_3: undefined_4: 2 Whatdate didthis condition first preventyour patientfrom workingor training 20hours: Month 1: Month 2: Month 3: Month 4: Month 5: Year 1: Year 2: Year 3: Year 4: Year 5: Month: to: to_2: to_3: to_4: Year 1_2: Year 2_2: Year 3_2: Year 4_2: Year 5_2: If yes anticipateddate when the Patientcouldperform 20hours 30hours 35: Doctor Name: Check Box2: Off undefined_5: Check Box3: Off Check wr: Off Check Box2jnod: Off Check Box2j l ]p: Off Check Box2nm,jo[: Off rmncrwk;: Off nl1kxkwx1: Off jwj;b1: Off Check Box21wml: Off Check Box2x1wk;n’ ;1w: Off Check Box21k; ;w’: Off Check Box21l’lw \”: Off Check Box2x1 mm =0-9: Off n3mp: Off c2ek; 2e ;: Off ”

pdf CalWORKs – CalWORKs School Verification Form for Children over 18 and less than 19

In CalFresh and CalWORKs

” VERIFICATION OF COMPLETION OF HIGH SCHOOL REQUIREMENTS The CalWORKs Rule. MPP 42-101.2 A child 18 years of age is eligible for CalWORKs only if he\/she is enrolled as a full-time student (as defined by the school) in high school or, if he\/she has not completed high school, in a vocational or technical training program which cannot result in a college degree, provided he\/she can reasonably be expected to complete either program before reaching age 19. NOTE: This does not require that a student graduate high school, but only that the school reasonably believes that the student would complete his or her high school requirements by the time he or she is 19 years of age. TO BE COMPLETED BY THE SCHOOL This is to certify that ____________________________________________ Name of Student is a full time student at this time and is reasonably expected to complete his\/her high school requirement on or before the date set forth below. Name of School Date Month Year SCHOOL CERITICATION X Signature of School Official Title Date Name of Student: Date: Year: Title: Year778: ojhpo: lmm: Title -98hub: ”

pdf CalWORKs – 24-month and 48-month time-clock extender form CW 2186A

In CalFresh and CalWORKs

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pdf CalWORKs & CalFresh – CalWORKs & CalFresh Estimating the value of car(s) Form

In CalFresh and CalWORKs

” CAR VALUE ESTIMATE 1. My name is ______________________________________________________ ` Name of Person Completing This Form 2. I am employed at ________________________________________________ Name of Company 3. I have ________ years of experience in the business of buying and selling cars. 4. On _______________ I estimated the value of ___________________________. date\/month\/year Year and Make of Car Estimated 5. The license number off the car is ______________________________________. 6. Based on my evaluation off the car, I estimate the present value of this car to be worth the sum of _________________dollars. 7. It is also my professional opinion, after examining the car and other relevant information, that the estimated value of the car commencing with the month of _____________ to the month of ______________the estimated value of this car would have been $ ___________. I hereby certify that the above statement is true and correct. Date:____________________________ By ________________________________________ Signature of Person Making the Estimate Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: ”

pdf CalFresh Form- CCWRO SNAP/CalFresh Purchase & Prepare Statement

In CalFresh and CalWORKs

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pdf CalFresh Form – How to Request to Recomputation of CalFresh Overissuance (OI) When CalWORKs Was Used to Compute the OI

In CalFresh and CalWORKs

” 1 How to Request to Recomputation of CalFresh Overissuance\/Underissuance For many years when the county discovered an overpayment for CalWORKs and CalFresh, they would use the overpaid CalWORKs grant to compute the CalFresh overissuance. For example. The notice would show that there was November 2019 CalWORKs overpayment. The CalWORKs payment made was $550, but the correct payment was $200, thus there is a $350 CalWORKs overpayment. The next envelope contains the CalFresh overissuance. The CalFresh overissuance calculation uses $550 instead of $200 to compute the CalFresh overissuance. ACIN I-16-05E states that All County Letter No. 03-18 provides that when determining the value of either an AE or IHE OI or UI, the County Welfare Department (CWD) must recreate case circumstances by using the CalWORKs grant amount the household should have received had the household reported the required information and the county taken timely action. All County Information Notice (ACIN) No. I-16-05 provided incorrect guidance on this same topic (question and answer page 12). This erratum corrects ACIN 1-16-05 and All County Information Notice reiterates guidance provided in ACL No. 03-18. This correction is effective as of the date of release of this letter. RE-CALCULATION OF EXISTING CLAIMS Households with established claims as of the release of this letter may request a re-calculation using the methodology clarified above. For those OIs or UIs that are in the process of being calculated as of the release of this letter, the methodology clarified above must also be used. WELFARE ADVOCATE PRACTICE GUIDE: If your customer has a CalFresh OI and a CalWORKs OP, you can use the form below to request recomputation of the CalFresh overissuance per ACIN-16-05E. Kevin M. Aslanian Executive Director Grace A. Galligher Directing Attorney Erin Simonitch, Staff Attorney Andrew Chen, Staff Attorney Daphne Macklin, Researcher 1111 Howe Avenue Suite 635 Sacramento, CA 95825-8551 Tel. (916) 736-0616 Fax (916) 736-2645 Kevin Aslanian Cell (916) 712-0071 ccwro.org Coalition of California Welfare Rights Organizations, Inc. CCWRO 2 Request to Recompute CalFresh Overissuance\/Underissuance Per ACIN I-16-05E I hereby request that the CalFresh OI\/UI computed by the county in my case be recomputed by using the correct CalWORKs payments based on the process outlined in ACIN I-16-05E. YOUR NAME (PLEASE PRINT): _________________________________________________________________________________________________ YOUR ADDRESS _________________________________________________________________________________________________ YOUR BIRTHDATE _________________________________________________________________________________________________ YOUR EMAIL ADDRESS _________________________________________________________________________________________________ YOUR SIGNATURE _________________________________________________________________________________________________ DO YOU NEED FREE LEGAL HELP? Coalition of California Welfare Rights Organizations (CCWRO) 1111 Howe Ave., Suite 635, Sacramento, CA 95825 Telephone (916) 712-0061 ccwro.org HOW TO USE THIS FORM? You can give this to your worker. You can mail us this form and we will give it to your worker if you authorize us to do so. If you want us to help you, you have to sign below authorizing us to help you. I, the undersigned authorize CCWRO and any person working with them to be my authorized representative for all purposes, including filing for a state hearing: Date___________ Your Signature________________________________________ process outlined in ACIN I1605E 1: process outlined in ACIN I1605E 2: process outlined in ACIN I1605E 3: process outlined in ACIN I1605E 4: authorized representative for all purposes including filing for a state hearing: ”

spreadsheet CalFresh Form – CalFresh Medical Transportation Verification form – 2020

In CalFresh and CalWORKs

“Sheet2 ACL – 17-35 -CalFresh Medical Transportation Verification for ________________________________ Date Month Year Destination (doctor’s office, hospital, pharmacy, etc.) Address Did you drive your own car? # of miles x IRS business mileage rate (round trip) Did you take public transportation? Ticket price (round trip) Did you pay someone else to drive you? Amount paid (round trip) I hereby certify that the above is true and correct. Signature of Beneficiary Date ”

pdf CalFresh – CCWRO CalFresh Student Verification Form

In CalFresh and CalWORKs

” COLLEGE ENROLLMENT VERIFICATION FORM FOR CALFRESH STUDENT NAME _____________ DOB ___ __ ____ SCHOOL NAME ___________________ 1. Enrollment Status ! Full Time ! Half Time ! Less Than Half-Time 2. Educational Goal ! Associate Degree ! Bachelor Degree ! Other: Specify 3. Student Participation in Other Federally Exempt Programs Does the student’s program meet the definition of the Carl D. Perkins Career and Technical Education Improvement Act of 2006 (Perkins IV) program in that the program is funded in part with Perkins IV money? Please indicate: Yes ! No ! 4. Student’s Participation in Work Study Has the above student eligible for a federal or state funded work-study program? Please indicate: Yes ! No ! 5. CalGrant Is the student getting CalGrant funds? Please indicate: Yes ! No ! _________________________________________________________________ NAME OF COLLEGE OFFICIAL TITLE _________________________________________________________________ SIGNATURE OF COLLEGE OFFICIAL DATE undefined: NAME OF COLLEGE OFFICIAL: TITLE: SIGNATURE OF COLLEGE OFFICIAL: DATE: DOB: DOB4: Text1: Check Box2: Off Text2: Text3: Check Box3: Off 1354: Off Check Box7: Off Check Box21q: Off Check24tgkm: Yes f13rvg: Off 13r5g;: Off Check Box2134,gg: Off 13l;mk: Off rv13mv: Off -134fv: Off ”

pdf CalFresh & CalWORKs Form – Loan Agreement for CalFresh and CalWORKs – 7-19

In CalFresh and CalWORKs

” LOAN AGREEMENT This is a loan agreement between Borrower(s) named and signed below, that commencing with period of through the period of , lender named and signed below will loan Borrower the sum of $ per month. Borrower hereby acknowledges that he has the obligation to pay all of this back to Lender commencing with _____________ of a monthly payment of $ for each and every month until repaid in full. Agreed to date:________ Borrower Name of Borrower(s) Signature Date Lender Name of Lender(s) Signature Date CalFresh Loan State Regulation – MPP 44-111.437 Loans other than those excluded in Sections 44-111.431 and .432 shall be exempt. A loan is defined as specified in Sections 44-111.437a., a.(1) and a.(2): a. A written agreement signed and dated by the lender and applicant\/recipient as parties to the agreement that clearly specifies: (1) the obligation of the applicant\/recipient to repay the loan; and (2) a repayment plan which provides for installments of specified amounts that continue on a regular basis until the loan is fully repaid. CalFresh Loan State Regulation- MPP 63-300(f)(2) Liquid Resources and Loans The county welfare department may verify liquid resources and whether monies received by households are loans. When verifying whether income is exempt as a loan, a legally binding agreement is not required. A simple statement signed by both parties which indicates that the payment is a loan and must be repaid shall be sufficient verification. However, if the household receives payments on a recurrent or regular basis from the same source but claims the payments are loans, the county welfare department may also require that the provider of the loan sign an affidavit which states that repayments are being made or that payments will be made in accordance with an established re- payment schedule. 63-502(f) (f) All loans, including loans from private individuals as well as commercial institutions, other than edu- cational loans on which repayment is deferred as specified in Section 63-502.2(e). period of: lender named and signed below will loan Borrower: the sum of: commencing with: undefined: for each and every month until repaid in full Agreed to date: Borrower Name of Borrowers: Signature: Date: Lender Name of Lenders: Signature_2: Date_2: ”

SSI

pdf SSI – SSI Room rental statement SSA 795.pdf

In SSI

” Form SSA-795 (2-76) Form Approved OMB No. 0960-0045 SOCIAL SECURITY ADMINISTRATION STATEMENT OF CLAIMANT OR OTHER PERSON NAME OF NUMBER HOLDER SOCIAL SECURITY NUMBER NAME OF PERSON MAKING STATEMENT (If not NH) RELATIONSHIP (to NH) Understanding that this statement is for the use of the Social Security Administration, I hereby certify that… ______________________________ rents a room in my home and pays me $______ per month. This is strictly a BUSINESS RELATIONSHIP and we do not consider ourselves as members of the same household. We are related as a parent and child. He\/She does have access to adequate cooking facilities and food storages. If someone other than ______________________________________ rented a room in your house, how much would you charge per month? $___________. If less, why? Please explain below. _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________ Is _______________________________ obligated to pay rent as a condition to stay? yes no I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal Law and \/or State Law. I affirm that all information I have given in this document is true. SIGNATURE OF PERSON MAKING STATEMENT Signature (First name, middle initial, last name) (Write in ink) SIGN HERE Date (Month, day, year) Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route) Telephone Numbers (Include Area Code) Home ( ) Work ( ) – City and State ZIP Code Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses 1. Signature of Witness 2. Signature of Witness Address (Number & street, City, State & ZIP Code) Address (Number & street, City, State & ZIP Code) NAME OF NUMBER HOLDER: SOCIAL SECURITY NUMBER: NAME OF PERSON MAKING STATEMENT If not NH: RELATIONSHIP to NH: rents a room in my home and pays me: per month This is strictly a: rented a room in your house how much: If less why Please explain below: would you charge per month 1: would you charge per month 2: would you charge per month 3: obligated to pay rent as a condition to stay: Date Month day year: Mailing Address Number and street Apt No PO Box Rural Route: City and State: ZIP Code: 1 Signature of Witness: 2 Signature of Witness: Text1: Text323: Address Number street City State ZIP Code: Address Number street City State ZIP Codevqek: ”

pdf SSI – SSI expense form

In SSI

” Social Security Administration Form Approved OMB No. 0960-0045 STATEMENT OF CLAIMANT OR OTHER PERSON Name of Wage Earner, Self-employed Person, or SSI Claimant Social Security Number Name of Person Making Statement (If other than above wage earner, self-employed person, or SSI claimant) Relationship to Wage Earner, Self-Employed Person, or SSI Claimant Understanding that this statement is for the use of the Social Security Administration, I hereby certify that the following are my average monthly expenses for the period of Normal household expenses 1. Mortgage payments $ 2. Property Insurance (annual divided by 12) $ 3. Property Taxes (annual divided by 12) $ 4. Food $ 5. Electricity $ 6. Gas $ 7. Water $ 8. Garbage Removal $ 9. Telephone $ 10. Cable TV $ 11. Security System $ 12. Home Repairs $ Personal expenses for the family (average monthly costs) 1. Recreation, social functions, movies, restaurants $ 2. Club membership $ 3. Charity donations $ 4. Clothing $ 5. Haircuts, manicures $ 6. Dental bills (after insurance) $ 7. Medical bills (after insurance) $ Installment payments 1. Car insurance $ 2. Car loan payment $ 3. Car expense (gas) $ 4. Credit Card monthly payments $ 5. Lay-away accounts $ 6. Other retail accounts $ 7. Miscellaneous expenses $ Form SSA-795 (09-2015) ef (09-2015) Signature (First name, middle initial, last name) (Write in ink) Date (Month, day, year) Telephone Number (Include Area Code ) I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment. SIGNATURE OF PERSON MAKING STATEMENT Mailing Address (Number and street, Apt. No.,P.O.Box, Rural Route) Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses. 1. Signature of Witness 2. Signature of Witness Address (Number and street, City, State, and ZIP Code) Address (Number and street, City, State, and ZIP Code) Privacy Act Statement Collection and Use of Personal Information Section 205a of the Social Security Act (42 U.S.C. 405a), as amended, authorizes us to collect the information on this form. We will use this information to determine your potential eligibility for benefit payments. Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested information may affect our ability to evaluate the decision on your claim. We rarely use the information you provide for any purpose other than for determining entitlement to benefit payments. However, we may use the information you give us for the administration and integrity of our programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include, but are not limited to, the following: 1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and\/or coverage; 2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and the Department of Veterans’ Affairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment or incorrect payments or delinquent debts under these programs. A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089, Claims Folders Systems. This notice and additional information regarding our programs and systems are available online at www.socialsecurity.gov or at your local Social Security office. Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Form SSA-795 (09-2015) ef (09-2015) City and State ZIP Code Name of Wage Earner Selfemployed Person or SSI Claimant: Social Security Number: Name of Person Making Statement If other than above wage earner selfemployed person or SSI claimant: Relationship to Wage Earner SelfEmployed Person or SSI Claimant: the following are my average monthly expenses for the period of: undefined: undefined_2: undefined_3: undefined_4: undefined_5: undefined_6: undefined_7: undefined_8: undefined_9: undefined_10: undefined_11: undefined_12: undefined_13: undefined_14: undefined_15: undefined_16: undefined_17: undefined_18: undefined_19: undefined_20: undefined_21: undefined_22: undefined_23: undefined_24: undefined_25: undefined_26: 1 Signature of Witness: 2 Signature of Witness: Address Number and street City State and ZIP Code: Address Number and street City State and ZIP Code_2: Text1: Text2: Text3: Text4: Text5: ”

pdf SSI – SSA 795 Continued benefits filing for formal reconsideration

In SSI

” NAME OF PERSON MAKING STATEMENT (If other than above wage earner, self-employed person, or SSI claimant) SOCIAL SECURITY NUMBER Understanding that this statement is for the use of the Social Security Administration, I hereby certify that – Form SSA-795 (8-2002) ef (12-2005) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION STATEMENT OF CLAIMANT OR OTHER PERSON RELATIONSHIP TO WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT Form Approved OMB No. 0960-0045 NAME OF WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT kevinaslanian Highlight 2. Signture of Witness Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses. I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. SIGNATURE OF PERSON MAKING STATEMENT Telephone Number (Include Area Code) – ( ) – Signature (First name, middle initial, last name) (Write in ink) SIGN HERE Date (Month, day, year) Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route) ZIP Code 1. Signture of Witness Address (Number and street, City, State, and ZIP Code) City and State Address (Number and street, City, State, and ZIP Code) Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Text2: Text4: Text5: I have been advised of my right to have my SSI Text7: continued to me pending the outcome of the appeal regarding the decision Text8: of SSA to reduce or stop my benefits. Text9: I understand that, if I lose my appeal, I will be asked to pay this money back, Text10: including all checks received after this action takes effect, through the months Text11: such benefits were received if the appeal is not decided in my favor. Text12: I have the right to ask that I not have to pay the money back. If I do ask, Text13: and if it is determined by SSA that my appeal was made in good faith and that Text14: I need my income and resources for ordinary and necessary living expenses Text15: or that other factors apply, I will not have to pay the money back. I also understand Text16: that SSA will provide me with more information about waiver recovery of Text17: an overpayment, if I would like it. Text18: I will not be asked to pay back any Medicaid benefits I received while I was appealing. Text19: If I win my appeal, any money I am owed will be paid. Text20: During this benefit continuation period and while my appeal is pending, I agree Text21: to promptly report to SSA any changes which may affect my right to receive Text22: benefits, working, changes in my income and resources, and living arrangements. Text23: I understand hat I turn down continued benefits during the specified 10-day Text24: period , I will not have the chance (if he 10-days have passed) to elect continued Text25: benefits again. Text26: I WANT CONTINED BENEFITS PENDING THIS RECONSIDERATION. Text27: Text28: STATEMENT OF CLAIMANT Text29: Text30: I acknowledge that I understand my responsibilities and that I have been Text31: given a copy of this signed statement regarding my choice of continuation Text32: options: Text33: Text34: Election: Text35: __ Yes. I want all benefits continued. If I do not get my benefits I will Text36: not be able to pay for food and shelter. Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Check Box1: Yes Text1: Text3: Text6: ”