” 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 ”