On-line Forms and Publications E - H

E | F | G | H

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E Forms

• EA 1 (08/99) - Emergency Assistance Application For Probation
• EA 1 CWS (08/99) - Emergency Assistance Application For Child Welfare Services
• EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account
• EBT 2216 (4/23) - EBT Surcharge Free - Direct Deposit Handout
• EBT 2259 (3/24) - Report Of Electronic Theft Of Benefits
• EBT 2259A (11/21) - EBT Scamming Acknowledgement
• EBT 2260 (8/21) - Excessive Card Replacement Warning Letter
• EDU 1 (6/21) - Nutrition Services Division / Program Integrity Unit appeal Request
• EDU 2220G (6/21) - Infant — Toddler Environment Rating Scale — Revised Summary Report: Fiscal Year 2019-2020
• EDU 7618 (6/21) - Notice Of Action - Approval
• EDU 7619 (6/21) - Notice Of Action - Denial
• EDU 7620 (6/21) - Notice Of Action - Due To A Change In Family Circumstances
• EDU 7621 (6/21) - Notice To Pay Fees Or Terminate Child Care Due To Delinquent Fees
• EDU 7622 (6/21) - Notice Of Action - Recertification
• EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility
• EFA 14 (9/24) - The Emergency Food Assistance Program (TEFAP) 2024 Income Guidelines
• EFA 15 (9/24) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2024 Income Guidelines
• EP 4 (12/99) - Summary Of FS/Employment & Training Program

F Forms

• FC 01A (12/16) - Transitional Housing Program Plus Foster Care (THP+FC) Program Cost Report
• FC 01B (12/16) - Transitional Housing Program Plus Foster Care (THP+FC) Program & Other Revenue
• FC 2 (3/22) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC)
• FC 2 NM (5/22) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC)
• FC 2 CL (11/02) - Audit Contact Log
• FC 3 (10/19) - Determination Of Federal AFDC-FC Eligibility
• FC 3A (Supplement) (11/04) - AFDC-FG/U Workshee
• FC 3 NM (10/19) - Determination Of Federal AFDC-FC Eligibility For NMD
• FC 8 (5/22) - Federal Eligibility Certification For Adoption Assistance Program
• FC 8 WKIndexNP (11/02) - Workpaper Numbering/Indexing System Non-Provisional Rate Audits
• FC 10 (8/09) - Income And Property Checklist For Federal Eligibility Determiniation - Adoption Assistance Program
• FC 18 (11/04) - Notification Of AFDC-Foster Care Transfer
• FC 24 (8/04) - Certification By County Welfare Department For The Reimbursement Of Title IV-E Funds For Pre-Placement Prevention
• FC 25 (10/04) - Outcomes For Emancipated Foster Youth
• FC 26 (10/04) - Transitional Housing Placement Program (THPP)/THP-Plus
• FC 32 (3/21) - Foster Care Program Accessible Costs Data Report
• FC 1633A (2/07) - SSI Screening Guide Section A - Disability Screening
• FC 1633B (2/20) - SSI Screening Guide Section B - Financial Screening
• FC 1633C (2/07) - SSI Screening Guide Section C - Application Inforamtion
• FC 1633D (2/07) - SSI Assessment Tool
• FC 1637 (5/14) - 90-Day Transition Plan
• FCR 1FFA (12/04) - Foster Family Agency - Data And Certification Sheet
• FCR 2FFA (5/09) - Program Description Checklist
• FCR 3FFA (7/03) - Days Of Care Schedule
• FCR 12FFA (2/05) - Total Program Cost Display (FCR 12 FFA)
• FCR 16 (10/17) - Group Home/Short Term Residential Therapeutic Program (STRTP) Shelter Costs Declaration And Survey
• FDU 001 (6/23) - Commodity Loss Report Form Commodity Supplemental Food Program (CSFP) The Emergency Food Assistance Program (TEFAP)
• FDU 002 (6/23) - Commodity Transfer Form Commodity Supplemental Food Program (CSFP) The Emergency Food Assistance Program (TEFAP)
• FDU 113 (3/24) - Civil Rights Annual Training Checklist For CSFP And TEFAP
• FSP 1 (8/14) - Family Stabilization Program Evaluation Request
• FSP 2 (8/14) - Family Stabilization Program Denial Notice - Use Until April 30, 2022
• FSP 2 (1/21) - Family Stabilization Program Denial Notice - Use Starting May 1, 2022
• FSP 3 (8/14) - Family Stabilization Program Notice of Change in Program Status

G Forms

• GEN 100 (11/20) - Examples Of Verification
• GEN 102 (1/22) - Appointment Letter
• GEN 107 (8/20) - Message From The County
• GEN 111 (11/20) - Employer Statement Form
• GEN 201-A (10/23) Income Verification
• GEN 201-R (10/23) Income Verification
• GEN 539 (3/23) - Merit Issue Complaint
• GEN 727B (5/19) - County Forms Order, with Instructions Do NOT download this file to your computer if you want to use it to order online - open the file within your web browser. You should have the latest version of Adobe PDF Reader installed on your computer to use this form online.
• GEN 788 (3/22) - Request To Stop My Benefits
• GEN 788LP (3/22) - Request To Stop My Benefits - Large Print
• GEN 853 (10/20) - Sworn Statement
• GEN 1031 (4/24) - Annual County Training Plan
• GEN 1179 (5/18) - Complaint of Discrimination
• GEN 1321 (1/24) - CDSS System And Application Access Form
• GEN 1321A (11/03) - HHSDC Teale Data Security Access Request
• GEN 1388 (6/21) - Language Accessibility Services Complaint Form
• GEN 1389 (3/16) - Functional Assessment Service Team (FAST) Leader Course Application
• GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case
• GEN 1391 (6/17) - CDSS eIEVS Access Request Form
• GEN 1395 (7/19) - CDSS Safe (SFT) Access Request
• GEN 2101 (3/24) - Non-Work Social Security Number Request Form

H Forms

• HCS 001 (1/22) - Home Care Organization Suboffice Request
• HCS 100 (7/23) - Application For Home Care Aide Registration or Renewal
• HCS 105 (3/19) - Home Care Aide Registry Request For Name/Address Change
• HCS 200 (11/22) - Application For A Home Care Organization License
• HCS 215 (11/21) - Home Care Organization Licensee Applicant Information
• HCS 281 (12/21) - Application Instructions For A Home Care Organization License
• HCS 308 (9/21) - Designation Of Home Care Organization Responsibility
• HCS 309 (10/21) - Partnership/Corporation/Limited Liability Company Organization Structure
• HCS 402 (2/19) - Home Care Organization Dishonesty Bond
• HCS 500 (11/21) - Registered Home Care Aide Training Log
• HCS 501 (10/19) - Personnel Record
• HCS 600 (6/21) - Home Care Organization Personnel Report
• HCS 9165 (10/21) - Board Of Directors Statement
• HCS 9183 (12/21) - Home Care Organization Association Request
• HCS 9184 (12/21) - Home Care Organization Disassociation Request

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