Documents

” 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: ”

” 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 ”

“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 ”

” 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: ”

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” 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: ”

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” 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: ”

” 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 ”

” 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 ”

” 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: ”

” 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: ”

” 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 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” 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 ”

” 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 ”