On-line Forms and Publications A - D

A | C | D

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• AAP 1 (11/22) - Request For Adoption Assistance Program Benefit
• AAP 2 (11/22) - Payment Instructions Adoption Assistance Program
• AAP 3 (6/22) - Reassessment Information - Adoption Assistance Program
• AAP 4 (11/24) - Eligibility Certification Adoption Assistance Program
• AAP 5 (9/18) - Adoptions Assistance Program Independent Adoptions Program
• AAP 6 (11/22) - Adoption Assistance Program Negotiated Benefit Amount and Approval
• AAP 7 (12/17) - Adoptions Assistance Program Statement Of Acknowledgement
• AAP 8 (9/18) - Adoption Assistance Program Nonrecurring Adoption Expenses Agreement
• AAP 9 (6/21) - Adoption Assistance Program (AAP) Level Of Care Rate Determination Matrix (AAP LOC Matrix) Instruction Guide
• AAP 9A (5/21) - Adoption Assistance Program (AAP)Level Of Care Rate Determination Protocol Matrix
• AAP 10 (10/21) - Prospective Or Adoptive Parent(s) Level Of Care (LOC) Reporting Tool
• ABCD 239.7A (8/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• ABCD 478A (5/20) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• ABCDM 228 (ENG/SP) (3/24) - Applicant's Authorization For Release Of Information
• ABCDM 229 (1/23) - Applicant/Recipient’s Authorization For Release Of Information To Community-Based Organization (CBO) In BenefitsCal
• AD 1A (4/22) - Parental Consent To Adoption (In Or Out-Of-California)
• AD 1F (4/15) - Parental Consent To Adoption Outside California In Armed Forces - Independent Adoption Program
• AD 2 (6/02) - Stepparent Adoption (Consent To Adoption By Parent Retaining Custody
• AD 2A/2B (5/11) - Stepparent Adoption (Consent to Adoption by a Parent in or outside of California Giving Custody to Husband or Wife or Domestic Partner of Other Parent)
• AD 2D (3/08) - Stepparent Adoption Consent To Adoption By Parent Outside California In Armed Forces Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent
• AD 9 (11/07) - Independent Adoption Questionnaire - Independent Adoptions Program
• AD 10 (9/03) - Request for Reference
• AD 20 (4/15) - Refusal To Give Parental Consent To Adoption - Independent Adoptions Program
• AD 20B (5/15) - Refusal To Give Consent To Adoption - Alleged Father - Independent Adoption Program
• AD 22 (7/02) - Health Facility Minor Release Report - Agency And Independent Adoptions Program
• AD 28 (8/03) - Notification Of Subsequent Action
• AD 29 (3/07) - Employment Verification
• AD 40 1 (8/03) - Adoptions Worksheet (Print 8 1/2 x 14)
• AD 42 I (3/02) - Independent Adoptions Program (Individual Case Report)
• AD 56D (1/02) - Independent Adoption Program & Adoption Set Asides - Independent Adoptions Program
• AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care
• AD 67 (7/24) - Information About The Biological Mother/Legal Parent - Agency And Independent Adoptions Program
• AD 67A (7/24) - Information About The Biological Father/Legal Parent - Agency And Independent Adoptions Program
• AD 90 (6/13) - Supporting Information For Issuance Of California Department Of Social Services Acknowledgement And Confirmation Of Receipt Of Child Freeing Documents
• AD 100 (9/22) - Authorization For Release, Use And/Or Disclosure Of Health And Other Information - Agency And Independent Adoption Programs
• AD 100A (7/20) - Authorization For Release, Use And/Or Disclosure Of Health Information
• AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In Or Out-Of-California) - Independent Adoptions Program
• AD 202B (11/23) - Intercountry Adoption Program Quarterly Statistical Report
• AD 501 (4/24) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father In California)
• AD 501A (4/24) - Relinquishment Out-of-State (Birth Mother/Biological Father/Presumed Father)
• AD 504 (5/15) - Relinquishment – Out of State In Armed Forces (Birth Mother/Biological Father/Presumed Father)
• AD 508 (7/13) - Rescission Request/Rescission Of Relinquishment
• AD 512 (12/24) - Psychosocial And Medical History Of Child
• AD 512 NMD (12/24) - Psychosocial And Medical History Of Non-Minor Dependent
• AD 513 NMD (8/22) - Non-Minor Dependent Adoption Mutual Disclosure Agreement
• AD 524 (Bilingual) (3/99) - Physician's Examination Of Adoption Applicant/Petitioner
• AD 551A (11/13) - Notification Of Procedure In Lieu Of Signing Relinquishment, Waiver or Denial (To Be Used For California Court Actions, Out-of-State Actions, And Foreign Born Children)
• AD 558 (7/10) - Notice Of Placement (To Be Sent Within 15 Days of Placement)
• AD 580 (7/10) - Notice of Removal Of Child From Adoptive Home
• AD 583 ENG/SP (5/15) - Relinquishment In Or Out Of County - Presumed Father Denies He Is The Birth Father in California
• AD 584 (8/12) - Relinquishment Out of State - Presumed Father Denies He is the Birth Father
• AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California)
• AD 588 (5/24) - Denial Of Paternity By Alleged Father - In Or Out Of California - Agency And Independent Adoptions Program
• AD 590 (4/15) - Waiver Of Right To Further Notice Of Adoption Planning (Alleged Father In Or Out Of California) - Agency And Independent Adoptions Program
• AD 590A (9/24) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Parent In Or Out Of California - Agency And Independent Adoptions Program
• AD 591 (12/14) - Relinquishment - Out-of-State (Alleged Natural Father)
• AD 593 (5/22) - Relinquishment – Out of State in Armed Forces (Alleged Natural Parent)
• AD 594 (5/24) - Alleged Father's Consent To Adoption (In Or Out Of California) - Independent Adoptions Program
• AD 824 (7/10) - Adoption Petition - Consent and Joinder
• AD 842 (3/17) - Alleged Father's Consent To Adoption (Outside California In The Armed Forces)
• AD 856 (7/23) - Notice To Discontinue Foster Care (FC) Payment
• AD 859 (8/15) - Parental Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program
• AD 860 (8/15) - Presumed Father's Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program
• AD 861 (8/15) - Consent To Adoption Of Indian Child By Alleged Father (In Or Out Of California) - Independent Adoption Program
• AD 862 (3/12) - Relinquishment Of An Indian Child Out-Of-State (Alleged Natural Father)
• AD 863 (9/12) - Relinquishment Of An Indian Child Out of State - Birth Mother/Presumed Father
• AD 864 (9/14) - Relinquishment Of An Indian Child In Or Out-Of-County - Birth Mother/Presumed Father In California
• AD 866 (10/14) - Relinquishment Of An Indian Child In Or Out-of-County - Presumed Father Denies He Is The Birth Father In California
• AD 867 (3/08) - Relinquishment of an Indian Child - Out-of-State - Presumed Father Denies He is the Birth Father
• AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California
• AD 880 (2/21) – Declaration Of Birth Parent - Agency And Independent Adoptions Program
• AD 885 (3/14) - Mother Or A Biological/Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian
• AD 885A (4/22) - Statement Of Understanding Agency Adoption Program - Parent Or A Presumed Parent Of A Child Who Is Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian
• AD 885C (2/15) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian
• AD 885D (11/21) - Statement of Understanding - Alleged Parent of a Child Who is Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal Guardian
• AD 887 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The Child To The Petitioner(s)
• AD 887A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s)
• AD 887B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father
• AD 898 (1/11) - Consent Of CDSS Or Delegated County Adoption Agency - Independent Adoptions Program
• AD 899 (3/08) - Statement of Understanding - Mother or a Presumed Father of the Indian Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or a Ward of a Legal Guardian
• AD 899A (11/21) - Statement of Understanding - Mother or a Presumed Father of an Indian Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 899C (3/06) - Statement Of Understanding - Alleged Natural Father of the Indian Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 899D (11/21) - Statement Of Understanding - Alleged Parent of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
• AD 900 (8/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The INDIAN Child To The Petitioner(s)
• AD 900A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The INDIAN Child To The Petitioner(s)
• AD 900B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father Of An INDIAN Child
• AD 902 (2/22) - Consent For Arranging Contact
• AD 904A (2/24) - Waiver Of Rights To Confidentiality For Siblings
• AD 904B (9/20) - Waiver Of Rights To Confidentiality For Siblings Under The Age Of 18
• AD 907 (5/24) - Adoptive Placement Agreement
• AD 907A (5/24) - Adoptive Placement Agreement for Non-Minor Dependent Adoption
• AD 908 (5/22) - Adoptions Information Act Statement
• AD 908A (1/11) - Adoptions Information Act Statement
• AD 918 (11/03) - Family Assessment Questionnaire II
• AD 924 (6/22) - Independent Adoption Placement Agreement - Independent Adoptions Program
• AD 925 (11/23) - Independent Adoption Placement Agreement - Indian Child - Independent Adoptions Program
• AD 926 (1/18) - Statement Of Understanding Independent Adoptions Program – Parent Who Places The Child With The Prospective Adoptive Parent(s)
• AD 927 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Indian Child With The Prospective Adoptive Parent(s)
• AD 928 (7/02) - Revocation Of Consent Independent Adoption Program - Independent Adoptions Program
• AD 929 (9/18) - Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program
• AD 929A (4/21) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program
• AD 930 (7/11) - Independent Adoption Placement Agreement Transmittal - Independent Adoptions Program
• AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment
• AD 932 (2/21) - Notice of Entry for Intercountry Adoptions
• AD 933 (12/20) - Intercountry Readoption Acknowledgment
• AD 934 (1/21) – Court Filing Cover Sheet For Intercountry Readoptions
• AD 4040 (7/20) - Private Adoption Agency Reimbursement Program (PAARP) (Posted July 1, 2020)
• AD 4310 (8/07) - Adoption Programs Notice Required By Information Practices Act
• AD 4313 (8/03) - Letter Requesting Parent Be Interviewed - Independent Adoptions Program
• AD 4317 (3/20) - Revocation Of Relinquishment
• AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement
• AD 4324 (5/24) - Adoption Questionnaire I This is a large PDF file. Tips for Using Adobe PDF Files
• AD 4328 (3/06) - Authorization For Release Of Personal Items
• AD 4336 (4/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (Outside California In Armed Forces) - Independent Adoption Program
• AD 4339 (12/14) - Relinquishment – Out of State (Birth Mother/Biological Father/Presumed Father)
• ADM 36 (6/99) - Medical Report Regarding Child To Be Adopted
• ADSA 1 (3/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits
• ADSA 1A (5/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits
• ADSA 1AL (11/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits - Large Print
• ADSA 1B (6/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits
• ADSA 1L (5/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits - Large Print
• ADSA 1BL (7/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits - Large Print
• ADSA 2 (10/21) – Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program 
• ADSA 2L (12/21) – Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program - Large Print
• ADSA 3 (10/21) - Assistance Dog Special Allowance (ADSA) Enclosure 
• ADSA 3L (11/21) - Assistance Dog Special Allowance (ADSA) Enclosure - Large Print
• AR 2 (11/13) - Reporting Changes For CalWORKs And CalFresh
• AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh
• AR 3 (2/15) - Mid-Year Status Report For CalWORKs and CalFresh
• ARC 1 (4/22) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program
• ARC 1A (6/21) - Rights, Responsibilities And Other Important Information For the Approved Relative Caregiver Funding Option Program (ARC)
• ARC 2 (10/19) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved
• AUD 1400 (5/24) - Audited Attendance And Fiscal Report For Special Programs For The Severely Handicapped
• AUD 2507 (5/24) - Audited Fiscal Report For Resource And Referral Programs
• AUD 9500 (5/24) - Audited Enrollment, Attendance And Fiscal Report For Child Care And Development Programs
• AUD 9500.1 (5/24) - Child Care And Development Programs Certified Children Days Of Enrollment And Attendance
• AUD 9500.2 (5/24) - Child Care And Development Programs Certified Children Receiving Mental Health  Consultation Services Days Of Enrollment And Attendance
• AUD 9500.3 (5/24) - Child Care And Development Programs Non-Certified Children Days Of Enrollment
• AUD 9500.4 (5/24) - Child Care And Development Programs Non-Certified Children Receiving Mental Health Consultation Services Days Of Enrollment
• AUD 9500A (5/24) - Audited Fiscal Report For Migrant Special Contracts
• AUD 9500AP (5/24) - Audited Fiscal Report For CALWORKs, Alternative Payment Or Family Child Care Home Programs
• AUD 9500SSC (7/24) - Audited Enrollment, Attendance And Fiscal Report For Child Care And Development Programs (For Single Service County)
• AUD 9529 (5/24) - Audited Fiscal Report For Child Development Support Contracts
• AUD 9530A (5/24) - Audited Reserve Account Activity Report

C Forms

• CAC 1 (3/22) - Request For One-Time Exception Corrective Action Plan
• CAC 3 (3/22) - Uncashed Child And Adult Care Food Program Reimbursement Remittance
• CCD 9 (7/21) - Equipment Purchase Approval Request
• CCD 11 (6/22) - Local Planning Council (LPC) County Priorities Report Form
• CCD 17 (7/22) - California County Local Child Care Planning Council Needs Assessment - Template
• CCD 19A (3/22) - Summary Request for Voluntary Temporary Interagency Transfer of Funds (Attachment A)
• CCD 19B (5/22) - Request to Release a Voluntary Temporary Transfer of the California Department of Social Services Contract Funds (Attachment B)
• CCD 19C (3/23) - Request to Accept a Voluntary Temporary Transfer of the California Department of Social Services Contract Funds (Attachment C)
• CCD 20 (4/22) - Out-of-State Travel Approval Request Form
• CCD 21 (9/24) - Parent Plan For Seeking Employment (PPSE)
• CCD 22 (8/23) - Equipment Inventory
• CCD 23 (9/21) - Fiscal Year 2021–22 Program Calendar
• CCD 23 (12/21) - Fiscal Year 2022–23 Program Calendar
• CCD 24 (10/23) - CCD Emergency Closure Requests For Fiscal Year
• CCD 25 (8/24) – Program Integrity Monitoring Tool
• CCD 26 (9/23) – Confidential Application for Child Development Services and Certification of Eligibility
• CCD 26A (10/24) –  Instructions for Completing Form CCD 26:  Confidential Application for Child Development Services and Certification of Eligibility
• CCD 27 (8/22) - Statement Of Parental Incapacitation
• CCD 28 (8/23) – Program Narrative Change – Fiscal Year
• CCD 29 11/22) - CD-ICW Income Calculation Work Sheet – Cash, Wages, Or Salary
• CCD 30B (7/24) - Subcontract Certification
• CCD 32 (9/23) - Program Staffing Plan (FY 2024–25 CCTR Expansion RFA)
• CCD 33 (11/21) - Continued Funding Application Program Calendar For Fiscal Year 2022-23
• CCD 33 (10/22) - Fiscal Year 2023-24 Program Calendar
• CCD 33 (9/23) - Fiscal Year 2024-25 Program Calendar
• CCD 33 (9/24) - Fiscal Year 2025-26 Program Calendar
• CCD 34 (10/23) - Fiscal Year 2024–25 General Child Care And Development Program Expansion Funds Request For Applications
• CCD 35 (8/22) - Educational Programs or Vocational Training Verification for Parent or Caretaker Attending Educational Programs or Receiving Vocational Training
• CCD 36 (12/21) - Child Ratio Schedule
• CCD 38 (3/22) - Site Supervisor or Program Director Staffing Qualifications Waiver Request
• CCD 39 (3/22) - Site Supervisor or Program Director Staffing Qualifications Waiver Extension Request
• CCD 43 (9/22) - Certification Statement Regarding Composition Of LPC Membership
• CCD 44 (8/24) - Board Resolution
• CCD 7617 (10/24) - Notice Of Action
• CCP 1 (3/15) - Declaration Of Exemption From TrustLine Registration And Health And Safety Self-Certification
• CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers)
• CCP 6 (8/99) - Health And Safety Facility Checklist
• CCP 7 (5/24) - CalWORKs Child Care Request Form And Child Care Payment Rules
• CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form
• CCP 9 (8/17) - Child Care Program (CCP) 9 Request For Policy Interpretation
• CCP 2145 (7/23) - CalWORKs Child Care Reimbursement Report
• CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read
• CF 10 (12/13) - Dependent Care Cost Affidavit
• CF 11 (8/23) - Notice To All CalFresh Recipients - Important - Please Read - Use Until September 30, 2024
• CF 11 (9/24) - Notice To All CalFresh Recipients - Use Starting October 1, 2024
• CF 12 (6/23) - Notice to CalFresh Recipients
• CF 12 LP (6/23) - Notice to CalFresh Recipients - Large Print
• CF 18 ENG/SP (2/14) - Important Information
• CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits
• CF 21 (3/14) - Release Form
• CF 24 (6/17) - CalFresh Program Request For Policy/Regulation Interpretation
• CF 28 Coversheet (2/14) - CalFresh Program Restricted Account Coversheet - Important To Know
• CF 28A (2/14) - CalFresh Program Restricted Account Agreement Part A
• CF 28B (2/14) - CalFresh Program Restricted Accounting Agreement Part B
• CF 30 (2/18) - SAR 7 Reminder Notice
• CF 30 LP (2/18) - SAR 7 Reminder Notice - Large Print
• CF 31 (6/19) - CalFresh Supplemental Form For Excess Medical Deductions
• CF 31LP (6/19) - CalFresh Supplemental Form For Excess Medical Deductions - Large Print
• CF 32 (6/13) - CalFresh Request For Contact
• CF 33 (6/19) - CalFresh Budget Worksheet - Special Medical/Shelter Deductions
• CF 37 (11/16) - Recertification For CalFresh Benefits
• CF 100 (11/20) - CalFresh Request For Authorized Representative Drug Or Alcohol Treatment Center Resident
• CF 101 (11/20) - CalFresh Request For Authorized Representative
• CF 211 (6/23) – CalFresh Notice of Provider Determination
• CF 285 (8/21) - Application For CalFresh Benefits
• CF 285 LP (8/21) - Application For CalFresh Benefits - Large Print
• CF 285A (11/21) - Application For CalFresh Benefits
• CF 286 SAR (12/15) - CalFresh Budget Worksheet/Semi-Annual Reporting Households
• CF 303 (7/24) – Replacement Or Disaster Supplement Affidavit
• CF 304A (9/20) - Important Information About Your CalFresh Benefits - CalFresh Water Pilot
• CF 304B (9/20) -Notice Of Approval For The CalFresh Water Pilot
• CF 304C (9/20) - Notice Of Discontinuance For The CalFresh Water Pilot
• CF 304D (10/22) - Notice Of CalFresh Water Pilot Extension
• CF 304E (7/23) - Notice Of CalFresh Water Pilot Extension Second Extension 
• CF 304F (10/24) - Notice of CalFresh Water Pilot Extension
• CF 377.1 (8/24) - Notice Of Approval For CalFresh Benefits
• CF 377.1 LP (10/23) - Notice Of Approval For CalFresh Benefits - Large Print 
• CF 377.1A (8/24) - Notice Of Denial Or Pending Status
• CF 377.1A LP (10/23) - Notice Of Denial Or Pending Status - Large Print
• CF 377.10 (2/24) - CalFresh Notice Of Denial/Disqualification For Failure To Meet General CalFresh Work Rules
• CF 377.11 (11/23) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement
• CF 377.11A (11/23) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11B (9/23) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11C (1/20) - CalFresh Informational Notice - CalFresh Time Limit For Able-Bodied Adults without Dependents (ABAWDs)
• CF 377.11D (1/20) – CalFresh Discretionary Exemption For Able-Bodied Adults Without Dependents (ABAWDs)
• CF 377.11E (12/23) – CalFresh Able-Bodied Adult Without Dependents (ABAWD) Time Limit Exemption Screening Form
• CF 377.2 (9/18) - CalFresh Notice Of Expiration Of Certification
• CF 377.2B (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members
• CF 377.2C (12/20) - CalFresh Notice Of Expiration Of Certification For Households With Only Elderly And/Or Disabled Members
• CF 377.2D (3/18) - CalFresh Notice Of Status Change For Households With Only Elderly And/Or Disabled Members
• CF 377.4 SAR (8/24) - CalFresh Notice Of Change For Semi-Annual Reporting Households
• CF 377.4 SAR LP (10/23) - CalFresh Notice Of Change For Semi-Annual Reporting Households - Large Print
• CF 377.4 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households
• CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report
• CF 377.5A (2/20) - Drug Addiction Or Alcoholic Treatment And Rehabilitation Centers And Group Living Arrangements: Periodic Resident Report
• CF 377.5B (1/20) - Drug Addiction Or Alcoholic Treatment Centers And Group Living Arrangements:  Change Report For Departing Residents
• CF 377.6 (8/13) - Information/Verification Needed
• CF 377.7A (2/14) - Notice Of Administrative Disqualification
• CF 377.7A1 (2/14) - Request For Restoration Of CalFresh Benefits After Administrative Disqualification
• CF 377.7B (6/22) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only
• CF 377.7B LP (6/22) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only - Large Print
• CF 377.7B1 (6/22) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice
• CF 377.7B1 LP (6/22) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice - Large Print
• CF 377.7C (2/14) - CalFresh Repayment Agreement For Inadvertent Household Errors Only
• CF 377.7D (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only
• CF 377.7D1 (1/14) - CalFresh Overissuance Notice For Administrative Errors (AE) Only
• CF 377.7D2 (6/22) - CalFresh Repayment Final Notice - County Administrative Error (AE)
• CF 377.7D2 LP (6/22) - CalFresh Repayment Final Notice - County Administrative Error (AE) - Large Print
• CF 377.7D3 (6/22) - CalFresh Overissuance Notice For Administrative Errors (AE)
• CF 377.7D3 LP (6/22) - CalFresh Overissuance Notice For Administrative Errors (AE) - Large Print
• CF 377.7E1 (1/14) - CalFresh Repayment Agreement For Administrative Errors Only
• CF 377.7F (10/17) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV)
• CF 377.7F LP (2/18) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV) - Large Print
• CF 377.7F1 (10/17) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV)
• CF 377.7F1 LP (2/18) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV) - Large Print
• CF 377.7G (3/18) - CalFresh Intentional Program Violation (IPV) Notice - Due To Trafficking
• CF 377.7H (2/23) - CalFresh Informational Notice - Potential Intentional Program Violation (IPV)
• CF 377.9 (8/20) - Notice Of Back CalFresh Benefits
• CF 377.9LP (8/20) - Notice Of Back CalFresh Benefits - Large Print
• CF 378A (11/24) - Minimum Nutrition Benefit Pilot Program Approval Notice
• CF 378B (11/24) - Minimum Nutrition Benefit Pilot Program Discontinuance Notice
• CF 385 (1/24) - Application For Disaster CalFresh
• CF 386 (2/14) - CalFresh Notice Of Missed Interview
• CF 387 (5/14) - CalFresh Request For Information
• CF 388 (7/24) - CalFresh Notice Of Restoration Approval
• CF 389 (7/24) - Notice Of Denial Of Restoration
• CF 390 (5/19) – Notice of Approval/Denial For Disaster CalFresh
• CF 478 (2/14) - Disqualification Consent Agreement CalFresh Program
• CF 485 (10/23) - CalFresh Elderly Simplified Application
• CF 485 LP (12/23) - CalFresh Elderly Simplified Application - Large Print
• CF 502 (2/23) - Notice To All CalFresh Recipients - End Of CalFresh Emergency Allotments
• CF 842 (2/14) - Claim Determination Worksheet
• CF 886 (11/23) - CalFresh Notice Of Work Rules
• CF 889 (12/23) - CalFresh Restaurant Meals Program Approval/Termination Notice of Action
• CF 1239 (12/20) - CalFresh Notice Of Approval/Denial/Termination Transitional Benefits
• CF 6177 (10/22) - CalFresh Student Exemption Screening Form
• CFAP 377.7B (8/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2025
• CFAP 377.7B1 (8/23) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2025
• CFAP 377.7C (7/23) – California Food Assistance Program (CFAP) - State CalFresh Repayment Agreement For Inadvertent Household Errors (IHE) - Use Starting October 1, 2025
• CFAP 377.7D2 (8/23) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice County Administrative Error (AE) - Use Starting October 1, 2025
• CFAP 377.7D3 (7/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice County Administrative Error (AE) - Use Starting October 1, 2025
• CFAP 377.7E1 (8/23) – California Food Assistance Program (CFAP) — State CalFresh Repayment Agreement For Administrative Errors - Use Starting October 1, 2025
• CFAP 377.7F (7/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV) - Use Starting October 1, 2025
• CFAP 377.7F1 (8/23) – California Food Assistance Program (CFAP) - State CalFresh Repayment Final Notice Intentional Program Violation (IPV) - Use Starting October 1, 2025
• CFAP 377.7F2 (7/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Intentional Program Violation (IPV) - Use Starting October 1, 2025
• CFAP 377.7G (8/23) – California Food Assistance Program (CFAP) - State CalFresh Intentional Program Violation (IPV) Notice Due To Trafficking - Use Starting October 1, 2025
• CFAP 377.7H (7/23) – California Food Assistance Program (CFAP) - State CalFresh Informational Notice Potential Intentional Program Violation (IPV) - Use Starting October 1, 2025
• CFAP 377.7T (8/23) – CalFresh/California Food Assistance Program (CFAP) State CalFresh Overissuance Repayment Agreement Transition Notice - Use Starting October 1, 2025
• CFAP 842 (7/23) – California Food Assistance Program (CFAP) - State CalFresh Claim Determination Worksheet - Use Starting October 1, 2025
• CFAP 1263 (7/23) – CalFresh/California Food Assistance Program (CFAP) - State CalFresh Combined Household Notice Of Action (Continued) - Use Starting October 1, 2025
• CF SSA 1 (7/24) - Information For Households Applying For CalFresh With The Social Security Administration
• CF SSA 1 LP (7/24) - Information For Households Applying For CalFresh With The Social Security Administration - Large Print
• CL 1 (7/23) - Cal-Learn Registration Program Information Orientation Appointment
• CL 2 (4/99) - Cal-Learn Program Requirements
• CL 3 (4/99) - Cal-Learn Notice Of A Participation Problem
• CL 4 (4/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant
• CL 8 (3/99) - Cal-Learn Notice Of Report Card Submittal Schedule
• CL 9 (3/99) - Cal-Learn Notice Of Good Cause Determination
• CL 10 (4/99) - Cal-Learn Notice Of Exemption/Deferral
• CL 11 (4/99) - Cal-Learn Notice Of Incomplete Grades
• CL 15 (1/00) - Cal-Learn Case Management Information Intercounty Transfer Form
• CL 16 (1/00) - Cal-Learn Case Management Inter-County Transfer Summary
• CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement
• CRF 01 (10/20) - Coronavirus Relief Fund (CRF) Certification Of Eligibility
• CSFP 001 (7/22) - Commodity Supplemental Food Program (CSFP) Participant Application
• CSFP 006 (7/22) - Commodity Supplemental Food Program (CSFP) Notice Of Action
• CSFP 008 (4/23) Commodity Supplemental Food Program (CSFP) Local Agency Interest Application
• CSFP 009 (4/23) Commodity Supplemental Food Program (CSFP) Notice of Action For Local Agency
• CSFP 010 (6/23) Commodity Supplemental Food Program (CSFP) Proxy Designation Form
• CSFP 011 (7/23) – Commodity Supplemental Food Program (CSFP) Alternate (PROXY) Pick Up Form
• CTRI 01 (10/20) - California Tax Return Information (CTRI) Notification To Client
• CW 2.1 N A (8/04) - Notice And Agreement For Child, Spousal And Medical Support
• CW 2.1Q (10/16) - Support Questionnaire
• CW 4 (6/02) - Immediate Need Payment Request
• CW 5 (7/01) - Veterans Benefits Verification and Referral
• CW 8 (11/14) - Statement of Facts For An Additional Person
• CW 8A (12/14) - Statement Of Facts To Add A Child Under 16
• CW 10 (7/01) - Notice of Withdrawn Application
• CW 13 (9/02) - Caretaker Relative Agreement
• CW 23 (3/00) - Senior Parent Statement Of Facts
• CW 25 (7/01) - Supplemental Statement of Facts - Minor Parent
• CW 25A (2/13) - Payee Agreement For Minor Parent
• CW 29 (1/13) - Applicant Test - Use Until June 30, 2022
• CW 29 (10/21) - Applicant Test - Use Starting July 1, 2022
• CW 30 (4/13) - CalWORKs Budget Worksheet - Use Until May 31,2020
• CW 30 (12/23) – CalWORKs Budget Worksheet - Use Starting June 1, 2020
• CW 31 SAR (4/13) - Receipt For Documents
• CW 40 (3/00) - CalWORKs - Reduced Income Supplemental Payment Request
• CW 42 (9/23) - Statement of Facts - Homeless Assistance
• CW 43 (3/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant
• CW 51 (10/11) - Child Support - Good Cause Claim For Noncooperation
• CW 52 (7/18) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Assistance Unit And Child Support Rules
• CW 52 (10/20) – California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Instead Of Cash Grant Option
• CW 60 (5/01) - Release Of Information - Financial Institution
• CW 61 (7/01) - Authorization to Release Medical Information
• CW 61A (6/01) - Physical Capacities
• CW 61B (6/01) - Mental Capacities
• CW 63 (11/20) - Request For Income And/Or Resource Verification
• CW 71 (3/00) - Statement Of Cash Aid Mother An Unrelated Adult Male (UAM)
• CW 74 (9/19) - Permanent Housing Search Document
• CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs
• CW 81 (4/10) - Lien Agreement
• CW 82 (3/00) - Coversheet - Agreement To Sell Property
• CW 86 (10/21) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program
• CW 87 (6/02) - Reinforming Letter/Add a Person(s)Program
• CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services - Use Until April 30, 2022
• CW 88 Coversheet (4/21) - You May Be Eligible For Diversion Services - Use Starting May 1, 2022
• CW 88 (6/11) - Diversion Services Agreement CalWORKs Program - Use Until April 30, 2022
• CW 88 (4/21) - Diversion Services Agreement CalWORKs Program - Use Starting May 1, 2022
• CW 89 (2/03) - Application Withdrawl Request
• CW 101 (7/17) - CalWORKs Immunization Rules
• CW 103 (11/09) - Multilingual - Transitional Medi-Cal
• CW 215 (10/19) - Notification Of Intercounty Transfer
• CW 371 (7/01) - Referral To Local Child Support Agency (LCSA)
• CW 377 (12/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV)
• CW 801 (11/00) - Summary Report Of Performance Incentives For Grant Reductions Due To Employment Earnings And Diversion For The California Work Opportunity And Responsibilities To Kids (CalWORKs)
• CW 801.2 (2/00) - California Work Opportunity And Responsibility To Kids (CalWORKs) Diversion Grant Summary
• CW 1725 (10/20) – School Attendance/Enrollment Verification
• CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old
• CW 2166 (7/19) - Multilingual Work Really Pays! Here's How - Use Until May 31, 2021 
• CW 2166 (12/20) - Multilingual Work Really Pays! Here's How  - Use Starting June 1, 2021
• CW 2166 (4/21) - Multilingual Work Really Pays! Here's How - Use Starting May 1, 2022
• CW 2166 (11/21) - Multilingual Work Really Pays! Here's How - Use Starting June 1, 2022
• CW 2184 (1/24) - CalWORKs 60-Month Time Limit - Use Starting October 1, 2024
• CW 2186A (1/24) - CalWORKs Exemption Request Form - Use Starting October 1, 2024
• CW 2186A (4/21) - CalWORKs Exemption Request Form - Use Starting May 1, 2022
• CW 2186B (12/12) - CalWORKs Exemption Determination - Use Until April 30, 2022
• CW 2186B (4/21) - CalWORKs Exemption Determination - Use Starting May 1, 2022
• CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit - Use Starting May 1, 2022
• CW 2188 (4/02) - Verification of Aid for Temporary Assistance for Needy Families (TANF) Program
• CW 2189A (9/20) – Notice Of Your CalWORKs Time Limit – 54TH Month On Aid (Use Starting May 1, 2022)
• CW 2189B (9/20) – Notice Of Your CalWORKs Time Limit – 57TH Month On Aid (Use Starting May 1, 2022)
• CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form - Use Starting May 1, 2022
• CW 2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Form - Use Until April 30, 2022
• CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form - Use Starting May 1, 2022
• CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits - Use Starting May 1, 2022
• CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits - Use Starting May 1, 2022
• CW 2200 (5/23) - Request For Verification
• CW 2200LP (5/22) - Request For Verification - Large Print
• CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form
• CW 2202W (9/15) - CalWORKs Program Request For Policy Interpretation
• CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit
• CW 2209 (12/14) - Immunization Good Cause Request Form
• CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed
• CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change
• CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs
• CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case
• CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment
• CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child) - Use Starting June 1, 2022 
• CW 2219 (5/16) Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child)
• CW 2222 (11/17) - CalWORKs Employment Bureau Request For Policy Interpretation
• CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs
• CW 2224 (2/20) - CalWORKs Home Visiting Program (HVP)

D Forms

• DFA 377.7A (4/21) - Notice Of Administrative Disqualification
• DFA 377.7D2 (10/00 ) - Food Stamp Repayment Notice For Administrative Errors Only Final Notice
• DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only
• DFA 377.7F (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV)
• DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV) - Large Print
• DFA 377.7F1 (10/00) - Food Stamp Repayment Notice For An Intentional Program Violation (IPV) Only Final Notice
• DFA 377.7G (5/02) - Food Stamp Repayment Agreement For An Intentional Program Violation (IPV) Only
• DFA 377.10 (6/04) - Food Stamp Notice of Denial/Disqualification
• DFA 874 (10/00) - Statewide Intercounty Lost Warrant Replacement Affidavit
• DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services
• DPA 19 (6/22) - Appointment Of Authorized Representative
• DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing
• DPA 435 (4/20) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification Hearing)
• DPA 436B (8/18) - County Information Letter
• DPA 479 (3/22) - Administrative Disqualification Hearing Waiver - CalWORKs/CalFresh
• DPA 481 (4/02) - County Report of Compliance Transmittal
• DPA 487 (5/07) - Request For Access To Protected Health Information
• DPA 488 (6/08) - Intentional Program Violation (IPV) Deletion Request Form
• DPA 489 (8/18) - Intentional Program Violation (IPV) Online System Request For Adding/Deleting /Modifying A User
• DPS 249 (12/10) - Welfare Intercept System County Transaction Document
• DPS 524 (3/00) - Disqualified Recipient Report