Chinese Translations

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Chinese Forms beginning with letters N through Z

Note: Unless otherwise indicated, all forms on this page have been translated into Traditional Chinese. 

For Chinese Forms beginning with the letters A through M:

A | B | C | D | E | F | G | H | I | J | K | L | M

A Forms

• AAP 1 (11/22) - Request For Adoption Assistance Program Benefit
• AAP 3 (6/22) - Reassessment Information - 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 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 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 65 (2/02) - Parent's Authorization For Medical And Surgical Care
• AD 67 (5/15) - Information About The Birth Mother - Agency And Independent Adoptions Program
• AD 67A (7/15) - Information About The Birth Father - Agency And Independent Adoptions Program
• AD 100 (9/22) - Authorization For Release, Use And/Or Disclosure Of Health And Other Information - Agency And Independent Adoption Programs
• 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 508 (7/13) - Rescission Request/Rescission Of Relinquishment
• AD 512 (1/14) - Psychosocial And Medical History Of Child
• AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California)
• AD 588 (4/15) - 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 (6/15) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Father In Or Out Of California - Agency And Independent Adoptions Program
• AD 591 (12/14) - Relinquishment - Out-of-State (Alleged Natural Father)
• 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 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 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 902 (2/22) - Consent For Arranging Contact
• AD 904A (2/24) - Waiver Of Rights To Confidentiality For Siblings
• AD 907 (5/24) - Adoptive Placement Agreement
• AD 908 (5/22) - Adoptions Information Act Statement
• AD 918 (11/03) - Family Assessment Questionnaire II
• AD 924 (5/15) - Independent Adoption Placement Agreement - Independent Adoptions Program
• AD 925 (11/23) - Independent Adoption Placement Agreement - Indian Child - Independent Adoptions Program
• AD 926 (4/14) - Statement Of Understanding Independent Adoptions Program – Parent Who Places The Child With The Prospective Adoptive Parent(s) - Independent Adoptions Program
• AD 928 (7/02) - Revocation Of Consent Independent Adoption Program
• AD 929A (4/21) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program
• AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment
• AD 933 (12/20) - Intercountry Readoption Acknowledgment
• AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement
• AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. Tips for Using Adobe PDF Files
• 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 (11/16) Rights, Responsibilities, And Other Important Information
• ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved

C Forms

• CCD 26 (9/23) – Confidential Application for Child Development Services and Certification of Eligibility
• CCD 26A (3/23) –  Instructions for Completing Form CCD 26:  Confidential Application for Child Development Services and Certification of Eligibility
• CCD 35 (8/22) - Educational Programs or Vocational Training Verification for Parent or Caretaker Attending Educational Programs or Receiving Vocational Training
• CCD 7617 (3/23) - 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 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 2145 (5/04) - 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 (2/14) ENG/Chinese - Important Information
• CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits
• CF 21 (3/14) - Release Form
• 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 29 (10/13) - CalFresh Recertification Appointment Letter
• CF 29A (2/14) - CalFresh Initial Appointment Letter
• CF 29B (2/14) - CalFresh Initial On-Demand Appointment Letter
• CF 29C (2/14) - CalFresh Recertification Appointment Letter
• CF 29D (2/14) - CalFresh Recertification On-Demand Appointment Letter
• 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 Special Medical Deductions
• CF 32 (6/13) - CalFresh Request For Contact
• CF 34 (12/20) – CalFresh Notice of Change: Semi-Annual Reporting Eliminated
• 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 285LP (4/21) - Application For CalFresh Benefits (20pt Font) - Use Starting June 1, 2019
• CF 285A (11/21) - Application For CalFresh Benefits
• CF 303 (7/24) – Replacement Or Disaster Supplement Affidavit
• CF 377.1 (5/20) - Notice Of Approval For CalFresh Benefits
• CF 377.1 LP (10/23) - Notice Of Approval For CalFresh Benefits - Large Print
• 377.1A (8/21) - Notice Of Denial Or Pending Status
• CF 377.1A LP (8/21) - 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 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households
• CF 377.4 SAR (9/23) - CalFresh Notice Of Change For Semi-Annual Reporting Households
• CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report
• 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 (10/17) - CalFresh Repayment Notice For 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 377.7F1 (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 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 478 (2/14) - Disqualifiction Consent Agreement CalFresh Program
• CF 485 (10/23) - CalFresh Elderly Simplified Application
• CF 485 LP (12/23) - CalFresh Elderly Simplified Application - Large Print
• 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
• 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
• CFAP 377.7B (8/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2025
• CL 1 (4/99) - 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
• CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement
• CSFP 001 (7/22) - Commodity Supplemental Food Program (CSFP) Participant Application
• CSFP 006 (7/22) - Commodity Supplemental Food Program (CSFP) Notice Of Action
• 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 Questionnnaire
• CW 4 (6/02) - Immediate Need Payment Request
• CW 5 (7/02) - 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 30 (12/23) – CalWORKs Budget Worksheet - Use Starting June 1, 2020
• CW 31 SAR (4/13) - Receipt For Documents
• 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 And 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) - Important Information About This Agreement
• 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 (6/11) - Diversion Services Agreement CalWORKs Program
• CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services
• CW 89 (2/03) - Application Withdrawl Request
• CW 101 (7/17) - CalWORKs Immunization Rules
• CW 103 (11/09) - Multilingual - Transitional Medi-Cal
• CW 377 (12/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV)
• CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old
• 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 2186B (4/21) - CalWORKs Exemption Determination - Use Starting May 1, 2022
• CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit - Use Until April 30, 2022
• CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit - Use Starting May 1, 2022
• CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program
• CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42th Month On Aid
• 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 Denial Form
• 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 (6/19) - Request For Verification (20pt Font)
• CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form
• CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit
• CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock
• 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 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 (6/19) - CalWORKs Home Visiting Initiative (HVI)
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D Forms

• DFA 377.1 (11/01) - Notice of Approval
• DFA 377.1A (3/02) - Notice Of Denial Or Pending Status
• 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 377.11B (11/00) - Food Stamp Notice Of Continuance
• DPA 19 (6/22) - Appointment Of Authorized Representative
• DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing
• DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification Hearing)
• DPA 436B (8/18) - County Information Letter
• DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/CalFresh

E Forms

• 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
• EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility
• EFA 7A (BI) (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility
• EFA 14 (3/24) - The Emergency Food Assistance Program (TEFAP) 2024 Income Guidelines
• EFA 15 (4/24) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2024 Income Guidelines

F Forms

• FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC)
• FCCH - Pre-Orientation Registration Information: Wait!
• FDU 113 (7/22) - Civil Rights Annual Training Checklist For CSFP And TEFAP
• FS 31 ENG/CH (2/09) - Notice To All Food Stamp Recipients - Important-Please Read - Things You Need To Know
• FSP 1 (8/14) - Family Stabilization Program Evaluation Request
• 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 102 (1/22) - Appointment Letter
• GEN 111 (11/20) - Employer Statement Form
• GEN 853 (10/20) - Sworn Statement
• GEN 1179 (5/18) - Complaint of Discrimination
• GEN 1388 (9/15) - Language Accessibility Services Complaint Form
• GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case
• GEN 2101 (3/24) - Non-Work Social Security Number Request Form
• HCS 100 (7/23) - Application For Home Care Aide Registration or Renewal

I Forms

• IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
• IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
• IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006)
• IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider
• IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits
• IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider’s Expiration Of Exemption From Workweek Limits

K Forms

• KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program
• KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents
• KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement
• KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form

L Forms

• LIC 01A (6/23) - Resource Family Application
• LIC 01C (7/16) - Resource Family Application-Confidential
• LIC 03 (7/23) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
• LIC 05A (8/21) - Resource Family Approval Certificate
• LIC 08 (2/24) - Intensive Services Foster Care Unit (ISFC) Written Assessment of Risk and Compatibility
• LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP)
• LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes
• LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home
• LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA
• LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA
• LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status
• LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities
• LIC 198B (9/23) - Out-Of-State Child Abuse/Neglect Report Request
• LIC 200 (2/24) - Application For A Community Care Facility or Residential Care Facility For The Elderly License
• LIC 279 (2/09) - Application For A Family Child Care Home License
• LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License
• LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency
• LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program
• LIC 300A (10/23) - Removal Confirmation - Exemption Needed
• LIC 301E (10/22) - Reference Request - Exemption
• LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children
• LIC 421CC (6/22) - Civil Penalty Assessment – Child Care
• LIC 421D (CC) (8/22) - Civil Penalty Assessment – Death/Serious Injury/Physical Abuse (Child Care)
• LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home
• LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility)
• LIC 508D (10/23) - Out-Of-State Disclosure And Criminal Record Statement
• LIC 610 (11/23) - Emergency Disaster Plan For Child Care Centers
• LIC 610 (11/23) - Emergency Disaster Plan For Child Care Centers (Simplified Chinese)
• LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes
• LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes (Simplified Chinese)
• LIC 613A (8/08) - Personal Rights - Child Care Centers
• LIC 613B (6/22) - Personal Rights Children’s Residential Facilities
• LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home
• LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes
• LIC 702 (8/08) - Child's Preadmission Health History - Parent's Report
• LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights
• LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights
• LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion)
• LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement)
• LIC 995E (10/09) - Caregiver Background Check Process
• LIC 995F (10/09) - Caregiver Background Check Information
• LIC 9052 (1/22) - Notice Employee Rights
• LIC 9058 (3/22) - Applicant/Licensee Rights
• LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse
• LIC 9121 (7/21) - Facility Visit Checklist Family Child Care
• LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC)
• LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form
• LIC 9150 (8/14) - Parent Notification - Additional Children in Care
• LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home
• LIC 9163 (7/24) - Request Live Scan Service - Community Care Licensing
• LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home
• LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart
• LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports
• LIC 9227 (8/20) - Individual Infant Sleeping Plan

M Forms

• M16_105 (7/02) - EBT Dormant Account
• M16-120A (6/11) - EBT Dormant Account
• M16-120B (6/11) - EBT Dormat Account: Suspend
• M16_120C (7/02) - EBT Dormant Account - Reactivate
• M16_215 (7/02) - EBT Availability
• M16_325A (7/02) - EBT Exemption Request
• M16_325B (7/02) - EBT Incomplete Document
• M16_325C (7/02) - EBT Exemption Deny
• M16-325D (8/08) - EBT Exemption Ended
• M16-325E (8/08) - Direct Deposit Cancellation
• M16-505A (8/08) - Designated Alternate Cardholder
• M16_505B (7/02) - Designated Alternate Cardholder - Need Additional Fact
• M16_505D (7/02) - Designated Cardholder - Deny
• M16-701 (8/08) - EBT Adjustment Advice
• M16-705 (6/23) - EBT Adjustment Denial 
• M20-003 (7/01) - Duplicate Aid Match, Discontinue
• M20-003A (7/01) - Duplicate Aid Match, Deny
• M20-353C (6/98) - Fraud, Penalty Applied to AU
• M20-353D (6/98) - Fraud, Penalty Applied to AU
• M20-353F (6/98) - Fraud, Penalty Stops - Change
• M40_105 (11/14) - Failed to Provide SSN When Received or Failure to Cooperate
• M40_105A (11/14) - Failed to provide SSN or proof of completed SSN Application
• M40_105B (7/98) - Change: Required Documentation Received, Immunization
• M40_105C (11/14) - Notice of Action - Immunizations
• M40_105D (7/98) - Change: Required Documentation Received, School Attendance
• M40-105D1 (1/15) - Notice Of Action - School Attendance
• M40_105E (2/15) - Notice of Action - School Attendance
• M40_105I (3/00) - Deny: SFIS Requirements, Failure to Cooperate
• M40_105J (3/00) - Deny: SFIS Requirements, Refusal to Cooperate
• M40-107 (6/11) - Addendum 1 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption
• M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40-107 (6/11) - Addendum 2 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption
• M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
• M40_107A (11/02) - Other: CalWORKs 60-Month Time Limit, Time on Aid (no previous NOA issued)
• M40-107A (4/21) - Time On Aid (no previous NOa issued), Other - Use Starting May 1, 2022
• M40_107B (6/11) - Time on Aid at Redetermination
• M40-107B (4/21) - Time On Aid at Redetermination - Use Starting May 1, 2022
• M40-107C (6/11) - Time On Aid Between 42th and 46th
• M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022
• M40-107D (6/12) - Time On Aid To Former CalWORKs Recipients
• M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients - Use Starting May 1, 2022
• M40_107F (6/11) - Extended Beyond 48 Months Of Aid
• M40-107F (4/21) - Extended Beyond 60 Months of Aid - Use Starting May 1, 2022
• M40-107F1 (4/21) - Extender Met After 60th Month - Use Starting May 1, 2022
• M40_107F1 (6/11) - Extender Met After 48th Month
• M40_107F2 (6/11) - Extender Ended
• M40-107F2 (4/21) - Extender Ended - Use Starting May 1, 2022
• M40_107G (11/02) - Discontinue: CalWORKs 60-Month Time Limit, 60th month on Aid
• M40-107G (4/21) - 60th Month On Aid, Discontinue - Use Starting May 1, 2022
• M40-107G (1/22) - 60th Month On Aid, Discontinue - Use Starting May 1, 2022
• M40_107H (11/02) - Change: CalWORKs 60-Month Time Limit, 60th month on Aid MFG child only
• M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue
• M40_107J (11/02) - Partial Approval: CalWORKs 60-Month Time Limit, Time-Out Adult
• M40-107J (4/21) - Timed-Out Adult, Partial Approval - Use Starting May 1, 2022
• M40_107J1 (6/11) - Approval after 48 Months On Aid
• M40-107J1 (4/21) - Approval After 60 Months on Aid - Use Starting May 1, 2022
• M40_107K (6/11) - Increase Grant due to TOA Adjustment
• M40-107K (4/21) - Increase Grant due to TOA Adjustment - Use Starting May 1, 2022
• M40_118A (8/96) - Application Processing Deny
• M40-125B SAR (4/16) - Restore After a SAR7 Discontinuance
• M40-125C SAR (4/16) - Incomplete Semi-Annual Report (SAR7) Denial of Restoration
• M40 129B (11/09) - Full Payment - Approve
• M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve
• M40-129C (12/90) - Miscellaneous, Deny
• M40-129D1 (11/14) - Procedural Requirements, Deny
• M40-129D2 (12/90) - Procedural Requirements, Deny
• M40-129D3 (12/90) - Procedural Requirements, Deny
• M40-129D4 (9/00) - Procedural Requirements, Deny
• M40_129D5 (11/14) - Failed to Provide Proof of SSN Application, Deny
• M40-129E1 (12/90) - No Emergency, Deny
• M40-129E2 (12/90) - No Emergency, Deny
• M40-129E4 (12/90) - No Emergency, Deny
• M40-129E5 (12/90) - No Emergency, Deny
• M40-129E6 (12/90) - No Emergency, Deny
• M40-171A (11/14) - Failure to Cooperate, Deny
• M40-171B (5/91) - Refusal to Cooperate, Deny
• M40_171C (6/98) - Approve: Application Processing, Basic Approval
• M40_171D (6/18) - Basic Approval
• M40_171M (7/87) - Denial: Application Processing, Not a California Resident
• M40 181 (9/13) - SAWS 2 Redetermination Of Eligibility
• M40-181A (11/14) - SAWS 2 Redetermination/Other Essential Information
• M40_181E (11/14) - SAWS 2 PLUS Redetermination Immunizations/School Attendance, Change
• M40 181C SAR (9/13) - Notice Of Action - Balderas Reminder Notice
• M40-181F (7/22) - No Change at Redetermination
• M40-181G (10/23) - Redetermination Reminder Notice
• M40-195A (8/22) - ICT Notice Of Transfer, Sending
• M40-195B (8/22) - ICT Notice Of Transfer, Receiving
• M41_401A (12/86) - Denial: Deprivation, No Deprivation
• M41_440F (6/98) - DENY: Deprivation, CalWORKs-U, 100 Hours Work Rule
• M41_450A (1/98) - Deprivation: Uniformed services - Deny
• M42_101B (11/14) - Age and School Requirements
• M42-101C (11/14) - Age and School Requirements, Discontinue
• M42 207A (10/15) - Over Property Limit, Deny
• M42-213A (11/14) - Restricted Account
• M42_221K (4/99) - Suspend: Property, Transfer w/out Fair Consideration
• M42_221L (4/00) - Suspend: Income, Transfer w/out Fair Consideration
• M42-431A4 (11/14) - No Eligible Noncitizen Status/Proof of Eligible Noncitizen Status, Discontinue
• M42-769A (11/14) - Apply $100 Cal-Learn Penalty
• M43_119E (1/98) - Sponsored Non-Citizen: Some needs Met - Change
• M43_119G (11/14) - Missing SAR 72, Change
• M43-119H (11/14) - Missing SAR 72, Discontinue
• M43_119I (7/98) - Change: Sponsored Alien, Deemed & Family Property
• M43_119J (7/98) - Change: Sponsored Alien, Deemed Property
• M43_119K (7/98) - DENY: Sponsored Alien, Deemed Property & Family Property
• M43_119L (7/98) - DENY: Sponsored Alien, Deemed Property
• M43_119M (1/98) - Sponsored non-Citizen: Deemed Income-Change
• M44_113A (6/98) - Change: Income, Change in Income
• M44_113G1 (6/98) - Change: Income, Change in Income
• M44 113H (11/12) - Change In Income
• M44_133D (6/98) - Change: Income, Change in Income
• M44_133Q (6/98) - Change: Income, Change in Income
• M44_133S (10/02) - Minor Parent Financial Eligibility (Change)
• M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval
• M44_133V (10/02) - Minor Parent Financial Eligibility (Suspend)
• M44-207I SAR (4/16) - Financial Eligibility
• M44_207J (6/98) - DENY: Income, Financial Eligibility Test
• M44_207L (6/98) - SUSPEND: Income, Financial Eligibility Test
• M44-207K (5/20) – Financial Eligibility, Discontinue
• M44-207K1 (5/20) - Minor Parent, Financial Eligibility
• M44-207M (8/20) - Financial Eligibility, Deny
• M44-211B (10/21) - Expanded Temporary HA For Applicants Fleeing DV, Approve
• M44-211D (9/23) - Temporary Shelter And/Or Permanent Housing
• M44-211L (9/23) - Pregnancy Special Needs, Approve
• M44-211N (9/23) -  Pregnancy Special Needs, Change
• M44-211O (9/23) - Discontinue Pregnancy Special Needs Payment for Pregnant Person Only Assistance Unit
• M44_305 (9/97) - Minor Parent Change of Payee
• M44_307A (11/15) - Voucher/Vendor Payment, Other
• M44_307B (1/99) - Voucher/Vendor Payment
• M44_307C (7/98) - Voucher Vendor Payment
• M44-315A (5/20) - $10 Minimum Payment, Change
• M44-315A (8/21) - $10 Minimum Payment, Change - Use Starting May 1, 2022
• M44_315B (9/98) - CHANGE: Aid Payment Levels, ICT between Reg-2
• M44 315C (4/09) - Notice of Action - Four Percent Grant Reduction
• M44 316 (8/04) - No Change/Mid Quarter Reporting
• M44 316 SAR (9/13) - No Change/Mid-Period Reporting
• M44 316A (9/13) - Notice Of Action - Not Yet Changed
• M44 316B (9/13) - Notice Of Action - Change In Income Over IRT
• M44-316C (8/22) - Notice Of Action - No Change/Mid-Period Report Of Property
• M44 316C SAR (10/17) - No Change/Mid-Period Report of Property
• M44 316D SAR (9/13) - Notice Of Action - Change In Income
• M44-316E (10/16) - Mid-Period Change Due To The Death Of A Child
• M44-340 (2/23) - Underpayment Adjustment, Approval
• M44 340C (8/12) - Underpayment Adjustment
• M44-350A (11/11) - Overpayment Adjustment
• M44-350E (11/11) - Excess Property O/P and Adjustment (W/O Good Faith)
• M44-350F (11/11) - Excess Property Overpayment Adjustment (W/O Good Faith)
• M44-350G (11/11) - Excess Prop O/P Adjustment (With Good Faith)
• M44-350H (11/11) - Excess Property Overpayment Adjustment (With Good Faith)
• M44-350I (11/11) - Notice of Overpayment
• M44-350I SAR (9/13) - Notice Of Overpayment
• M44-350J (3/12) - Overpayment To Be Stopped Effective February 1, 2012
• M44-350K (6/24) - EBT Replacement Denial
• M44-350L (12/18) - Notice Of Overpayment
• M44_352A (11/11) - Notice of O/P and Demand
• M44_352C (11/11) - Overpayment Recovery
• M44_352D (11/11) - Overpayment Recovery
• M44_352G (11/11) - Demand: Overpayment
• M44-352H (2/23) - Overpayment Adjustment 
• M44 352H SAR (9/13) - Notice Of Action Overpayment Adjustment
• M44-353 (2/24) - Notice Of Overpayment Discharge
• M44_401A (6/98) - Approve: Hardship Supplement RISP - MFG
• M44_401B (6/98) - Deny: Hardship Supplement RISP - MFG
• M81_215A (6/98) - DENY: Aid Payments, Diversion payment provided
• M81_215B (6/98) - DENY: Aid Payments, Diversion services provided
• M81_215D (6/98) - Change: Aid Payments, Diversion Repayment Stops
• M81_215E (6/11) - Time Limit Diversion
• M81-215E (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M81_215F (6/11) - Time Limit Diversion
• M81-215F (4/21) - Time Limit Diversion - Use Starting May 1, 2022
• M82-506 (6/98) - Change: Assignment of Support Rights, Failure to Cooperate
• M82-506A (6/98) - Partial Approval: Assignment of Support Rights, Failure to Cooperate
• M82-510 (6/02) - Failure to Cooperate, Change
• M82-510A (6/98) - Change: Support Process/Assignment, Cooperate
• M82-812 (4/04) - Family Reunification/Zero Grant
• M82-812A (6/24) - Start of Cash Aid for Family Reunification Case
• M82-812B (6/24) - End of Cash Aid Following Family Reunification Discontinuance - Child Returned to Home
• M82-812C (6/24) -  Family Reunification - End of Cash Aid
• M82-820A (9/21) - No Eligible Person, Deny
• M82-820D (9/23) - No Longer Eligible, Discontinue
• M82-832A (2/99) - Change: Aid Payments, Fleeing Felons
• M82-832B (2/99) - Partial Approval: Application Processing, Fleeing Felons
• M82-832E (4/15) - Eligible Person Leaving AU, Change
• M82-832F (4/15) - Eligible Person Leaving AU, Discontinue
• M82-832G (6/18) - Eligible/Mandatory/Optional Person Leaving AU
• M82-832H (10/20) - Child Does Not Meet Requirements (SB 380)
• M82-836A (8/91) - Denial: Au Composition, Unborn not Eligible for Aid
• M89_110 (1/98) - Exempt: Change
• M89_110A (1/98) - Non-Exempt Change
• M89_110B (1/98) - Exemption: Deny
• M89-130 (1/02) - Restricted Account, Discontinue
• M89_201 (11/96) - Minor Parent exemption: Deny
• MT42_101.2D (11/04) - Fry vs Saenz Lawsuit Age Requirement - Change
• MT42_101.2E (11/04) - Fry vs Saenz Lawsuit Age Requirement - Discontinue

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