Chinese Translations

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Chinese Forms beginning with letters A through M

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

For Chinese Forms beginning with the letters N through Z:

N | O | P | Q | R | S | T | U | V | W | X | Y | Z

N Forms

• NA Back 9 (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412)
• NA 200 (12/20) - Notice Of Action - Multipurpose - Include Budget - Use Starting June 1, 2021
• NA 200 (7/21) - Notice Of Action - Multipurpose - Include Budget - Use Starting June 1, 2022
• NA 210 (5/20) - Discontinue, Suspend Financial Eligibility - Use Starting June 1, 2020
• NA 213 (10/21) - Deny - Financial Eligibility
• NA 213A (12/20) – Notice Of Action – Deny – Financial Eligibility - Use Starting June 1, 2021
• NA 213A (7/21) – Notice Of Action – Deny – Financial Eligibility - Use Starting June 1, 2022
• NA 271 (12/20) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid - Use Starting June 1, 2021
• NA 271 (7/21) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid - Use Starting June 1, 2022
• NA 274E (6/11) - Notice of Action - Overpayment Computations For 1/1/98 to 6/30/11
• NA 274F (6/11) - Notice Of Action - Overpayment Amount Owed (For Overpayments Occurring on or after 7/1/2011)
• NA 274G (7/19) - Notice Of Action - Continuation Page - Overpayment Computations Occurring On Or After 10/1/2013 To 5/31/2020
• NA 274H (12/20) - Notice Of Action - Continuation Page - Overpayment Computations Between 6/1/2020 and 05/31/2021
• NA 274I (7/21) - Notice Of Action - Continued - Overpayment Amount Owed For Overpayments Occurring Between 6-1-2021 and 5-31-2022
• NA 274J (7/21) - Notice of Action – Continued - Overpayment Amount Owed For Overpayments Occurring On or after 6-1-2022
• NA 275 (4/99) - Continuation Page - Overpayment Adjustment Computation - Cash Aid
• NA 281 (6/11) - Notice Of Action Underpayment Amount Owed (For Underpayments Occurring on or After 1-1-98 thru 6-30-2011)
• NA 281A (6/11) - Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 7/1/2011)
• NA 281C (7/19) - Notice Of Action - Continuation Page - Underpayment Computations Occurring On Or After 6/1/2020
• NA 281C (12/20) - Notice Of Action Continuation Page - Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2020 and 5-31-2021) – Use Starting June 1, 2021
• NA 281D (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2021 and 5-31-2022)
• NA 281E (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring On Or After 6-1-2022)
• NA 290 (2/14) - Notice of Action - Multipurpose
• NA 300 (7/19) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Test - Use Until May 31, 2021
• NA 300 (10/21) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Tests - Use Starting June 1, 2021
• NA 301 (10/21) - Continuation Page - Applicant Financial Eligibility Test
• NA 320 (10/23) - In-Home Supportive Services (IHSS) Description of Services
• NA 320 LP (10/23) - In-Home Supportive Services (IHSS) Description of Services - (Large Print)
• NA 403 (4/17) Notice Of Action - For Resource Families, including homes certified by a Foster Family Agency, County Approved Relative Homes, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians
• NA 403A (4/17) Notice Of Action – Change For Kinship - Guardians Only
• NA 530 (4/11) - Notice Of Action 48-Month Time Limit
• NA 530 (4/21) - Notice Of Action - 60-Month Time Limit - Use Starting May 1, 2022
• NA 531 (12/20) - Notice Of Action - Continuation Page - 48-Month Time Limit - Includes Budget - Use Starting June 1, 2021
• NA 531 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget - Use Starting May 1, 2022
• NA 531 (7/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget - Use Starting June 1, 2022
• NA 532 (12/20) - Notice Of Action - Continuation Page - 48-Month Time Limit Discontinue - Includes Budget - Use Starting June 1, 2021
• NA 532 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit Discontinue - Includes Budget - Use Starting May 1, 2022
• NA 532 (11/21) - Notice Of Action - Continuation Page - 60-Month Time Limit Discontinue - Includes Budget - Use Starting June 1, 2022
• NA 690 (3/03) – IHSS Notice of Action
• NA 691 (9/23) - Notice of Denial - Cash Assistance Program For Immigrants (CAPI)
• NA 692 (9/23) - Notice of Change - Cash Assistance Program For Immigrants (CAPI)
• NA 693 (9/22) - Notice of Approval - Cash Assistance Program For Immigrants (CAPI)
• NA 791 (10/23) - Notice Of Action - Approval/Denial/Change
• NA 816 (3/14) - Notice of Action - Sanction Of Other Parent After Failed Compliance Plan
• NA 816A (1/24) - Notice Of Action - Sanction Of Other Parent After Failed Compliance Plan (FR)  - Use Starting January 1, 2025
• NA 817 (3/14) - Notice Of Action - Sanction Of Participant After Failed Compliance Plan
• NA 817A (6/24) - Notice Of Action - Disqualification After Failed Compliance (FR) - Use Starting January 1, 2025
• NA 817B (4/24) - Notice Of Action - Sanction Of Participant in Two-Parent AU After Failed Compliance Plan (FR) - Use Starting January 1, 2025
• NA 818 (3/14) - Notice Of Action - Taking You Out Of Welfare To Work
• NA 820 (11/20) - Notice Of Action - Transportation Approval
• NA 821 (11/20) - Notice Of Action - Transportation Approval/Denial
• NA 822 (7/16) - Notice Of Action - Transportation Change
• NA 823 (8/00) - Notice Of Action - Ancillary Expenses Approval/Denial
• NA 824 (4/99) - Notice Of Action
• NA 825 (8/00) - Notice Of Action - Payment Adjust Transportation
• NA 827 (7/99) - Notice Of Action - Recoupment Unused Advance Payment
• NA 828 (7/99) - Notice Of Action - Transportation And Ancillary Exp Overpayment
• NA 832 (3/20) - Notice of Action - Child Care Services
• NA 833 (4/20) - Notice of Action - Child Care Services Change
• NA 834 (3/20) - Notice Of Action - Child Care Denial
• NA 835 (10/17) - Notice of Action - Child Care Discontinuance
• NA 840 (3/14) - Notice Of Action - Welfare To Work Plan
• NA 840B (4/24) - Notice of Action - Welfare-To-Work Plan – Denial (FR) - Use Starting January 1, 2025
• NA 840C (5/24) - Notice Of Action - Welfare to Work Plan in a Two-Parent AU (FR) - Use Starting January 1, 2025
• NA 840D (4/24) - Notice of Action - Welfare To Work Plan Continuance/Discontinuance (FR) -  Use Starting January 1, 2025
• NA 841 (3/14) - Notice Of Action - Welfare-To-Work Plan
• NA 843 (6/99) - Notice of Action - Ineligible
• NA 844 (8/99) - Notice of Action - Adequate Progress
• NA 845 (3/14) - Notice Of Action - Sanction and Removal Of The Other Parent's Needs
• NA 845A (5/24) - Notice Of Action -Sanction and Removal Of The Other Parent's Needs (FR) - Use Starting January 1, 2025
• NA 960X SAR (9/13) - Notice Of Action - Stop Aid; Report Not Received
• NA 960Y SAR (10/14) - Notice Of Action - Stop Aid; Report Incomplete
• NA 991 (10/03) - Refugee Cash Assistance (RCA)/Entrant Cash Assistance (ECA) MC-Decrease/Expiration (Time-Expiration)
• NA 992 (5/03) - Refugee Cash Assistance (RCA) Application Approval
• NA 995 (5/13) - Food Stamp Notice Of Denial/Disqualification For The California Food Assistance Program
• NA 1208 (2/00) - Notice Of Action - Basic Approval
• NA 1209 (2/02) - Notice of Action - Change In The Amount Of Kin-Gap Payment
• NA 1210 (4/02) - Notice Of Action - Discontinue
• NA 1211 (2/00) - Notice Of Action - Denial
• NA 1212 (2/00) - Notice Of Action - Discontinue Property
• NA 1213 (2/00) - Notice Of Action - Discontinue Restricted Account
• NA 1214 (2/00) - Notice Of Action - Change Under/Overpayment
• NA 1217 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice of Overpayment
• NA 1218 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment
• NA 1230 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Approval
• NA 1231 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Partial Waiver Approval
• NA 1232 (9/23) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Denial
• NA 1239 AR (12/20) - Notice Of Action - Continuation Page - Annual Reporting Budget  - Use Starting June 1, 2021
• NA 1239 AR (8/21) - Notice Of Action - Continuation Page - Annual Reporting Budget - Use Starting June 1, 2022
• NA 1239 SAR (12/20) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget - Use Starting June 1, 2021
• NA 1239 SAR (8/21) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget - Use Starting June 1, 2022
• NA 1240 (4/13) - Notice of Action - Food Stamp Overissuance & Dormant EBT Account
• NA 1250 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Approval
• NA 1250L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval
• NA 1251 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation
• NA 1251L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation
• NA 1252 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Denial
• NA 1252L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Denial (18pt Font)
• NA 1253 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Change
• NA 1253L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change
• NA 1254 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation
• NA 1254L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation
• NA 1255 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Termination
• NA 1255L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Termination
• NA 1256 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cos
• NA 1256L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cost
• NA 1257 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Multi
• NA 1257L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Multi
• NA 1261 (10/09) - Overpayment AFDC-Foster Care Benefits
• NA 1261A (1/16) - Notice of Action - Form and Instructions- For Approved Relatives, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians or Non-Minor Dependents Residing In A Supervised Independent Living Setting
• NA 1261B (1/16) - Notice of Action - Form And Instructions - For Kinship-Guardians Only
• NA 1263 (8/11) - Notice of Action - Overissuance Budget Worksheet
• NA 1267 (4/13) - CalFresh Informing Notice Of Receiving Intercounty Transfer
• NA 1268 (4/13) - CalFresh Informing Notice Of Sending Intercounty Transfer
• NA 1269 (11/11) - Notice of Action - Approve Non-Minor Dependent
• NA 1270 (11/11) - Notice of Action - Discontinue Non-Minor Dependent
• NA 1273 (7/13) - Electronic Notification Agreement
• NA 1274 (7/13) - Electronic Notification Notice
• NA 1275 (7/13) - Electronic Notification Cancellation Notice
• NA 1276 (1/15) - Notice Of Action - Welfare-to-Work 24-Month Time Clock Limit Notice
• NA 1277 (1/16) - Notice Of Action - Approved Relative Caregiver (ARC) Overpayment
• NA 1278 (11/16) - Notice Of Action - Approve Approved Relative Caregiver (ARC) Payment
• NA 1279 (11/16) - Notice Of Action - Deny Approved Relative Caregiver (ARC) Payment
• NA 1280 (11/16) - Notice of Action - Discontinue Approved Relative Caregiver (ARC) Payment
• NA 1281 (11/16) Notice Of Action - Change Approved Relative Caregiver (ARC) Payment
• NA 1282 (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay
• NA 1282L (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay
• NA 960XQR (7/04) - Stop Aid; Report Not Received
• NA 960YQR (7/04) - Stop Aid; Report Incomplete
• NA IHSS Back L (3/15) - Your Hearing Rights

P Forms

• PUB 13 (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California
• PUB 13L (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California (Large Print)
• PUB 56 (12/06) - The In-Home Supportive Services Program
• PUB 104 (12/06) - In-Home Supportive Services Individual Provider Benefits and Services Information
• PUB 190 (8/06) - How To Hire And Supervise Your In-Home Supportive Services (IHSS) Provider
• PUB 203 (1/04) - In-Home Supportive Services - Guide to Workers’ Compensation Benefits for Individual Providers
• PUB 271 (2/17) - Never Shake a Baby Brochure
• PUB 271 (2/17) - Never Shake a Baby Brochure (Black & White)
• PUB 273-A2 (1/17) Shaken Baby Syndrome Poster - ( 24" x 36")
• PUB 275 (4/07) - Family Planning...Making the Commitment for a Healthy Future
• PUB 337 (9/12) - Statewide Fingerprint Imaging System (SFIS)
• PUB 367 (4/13) - Reach For Your Dreams With Cal-Learn
• PUB 370 (10/05) - Public Benefits For Asylees In California
• PUB 373 (Print 8 1/2 X 11) (5/07) - Important Food Stamp Information For Noncitizens
• PUB 373 (Print 11 X 17) (5/07) - Important Food Stamp Information For Noncitizens
• PUB 388 (2/24) - California Electronic Benefit Transfer (EBT) Card
• PUB 389 (2/24) - California Electronic Benefit Transfer (EBT) Card - How To Use Your EBT Card To Make A Purchase
• PUB 393 (12/06) - Notification of Parents' Rights - Child Care Center
• PUB 394 (12/06) - Notification of Parents' Rights - Family Child Care Home
• PUB 400 (08/17) - Safely Surrendered Baby Campaign Brochure
• PUB 400C-1 (6/17) - Safely Surrendered Baby Law - Know Your Rights Poster
• PUB 412 (4/04) - State Hearing Information
• PUB 428 (12/23) - It's Your Money - Get It - The State and Federal Earned Income Tax Credit (EITCs)
• PUB 429 (12/23) - California EITC is Here! Claim Your 2023 State And Federal Credits - You Earned It - It's Your Money
• PUB 463 (10/13) - Education Travel Reimbursement
• PUB 470 (4/21) - Your Rights Under Adult Protective Services
• PUB 470L (1/19) - Your Rights Under Adult Protective Services
• PUB 474 (12/14) - Rights of Resident Councils
• PUB 475 (10/18) - Residential Care Facility for the Elderly (RCFE) Complaint Poster
• PUB 484 (7/15) - Keep More Of Your Money - Poster
• PUB 515 (10/19) - Risks and Effects of Lead Poisoning
• PUB 516 (9/19) - You May Be Eligible For 12 Months Of Child Care
• PUB 520 (11/21) - Great News! Based On Your Medi-Cal Eligibility Your Household May Be Eligible For CalFresh Food Benefits
• PUB 521 (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Adults
• PUB 521L (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Adults (Large Print)
• PUB 522 (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Minor Children
• PUB 522L (10/21) - In-Home Supportive Services (IHSS) Protective Supervision Services For Minor Children (Large Print)
• PUB 525 (11/23) - Protect Yourself From Electronic Theft By Downloading The ebtEDGE Mobile Application Today
• PUB 526 (12/23) - You May Be Eligible For Retroactive CalFresh Benefit Theft Replacements

Q Forms

• QR 377.1 (4/04) - Food Stamp Notice Of Approval
• QR 377.2 (10/11) - CalFresh Notice Of Expiration Of Certification
• QR 377.4 (1/04) - Food Stamp Notice Of Change For Quarterly Reporting Household
• QR 377.5 (2/04) - Food Stamp Mid-Quarter Status Report
• QR 2103 (11/11) - Reminder For Teens Turning 18 Years Old

R Forms

• RAD 03 (2/21) – Suspected Unemployment Insurance Fraud And identity Theft Information
• RCA 43 (5/03) - Refugee Cash Assistance (RCA) Notice Of A Participation Problem(RCA)
• RCA 44 (5/03) - Refugee Cash Assistance (RCA) Notice Of No Good Cause Determination And Compliance Plan Appointment(RCA)
• RFA 00 (8/17) - Conversion to Resource Family: Release of Information
• RFA 00A (2/17) - Conversion - Resource Family Application
• RFA 01A (10/22) - Resource Family Application
• RFA 01B (7/19) - Resource Family Criminal Record Statement
• RFA 03 (8/22) - Resource Family Home Health And Safety Assessment Checklist
• RFA 05 (1/23) - Resource Family Approval - Written Report
• RFA 05A (8/22) - Resource Family Approval Certificate
• RFA 06 (9/23) - Resource Family Approval: Update Report
• RFA 07 (2/18) - Resource Family Approval (RFA) Health Questionnaire
• RFA 09 (5/24) - Notice of Action Regarding Resource Family Approval
• RFA 09B (4/18) - Notice Of Action To Individual Regarding Resource Family Approval Criminal Record Exemption Decision
• RFA 09E (9/17) - Order To Individual of Exclusion From Resource Family Homes And Department Licensed Facilities
• RFA 09I (9/17) - Order To Individual Of Immediate Exclusion From Resource Family Homes And Department Licensed Facilities
• RFA 10 (12/19) – Resource Family Approval Portability Application
• RFA 11 (12/19) – Resource Family Approval Statement Acknowledging Requirement To Report Child Abuse
• RFA 12 (3/21) - Resource Family Approval Documented Alternative Plan (DAP)
• RFA 13 (6/24) - Resource Family Approval - Video Camera Agreement Form
• RFA 105 (11/19) – Notice of Action – Issuance Emergency Caregiver Funding
• RFA 105A (11/19) – Notice of Action – Discontinue Emergency Caregiver Funding
• RFA 809 (5/24) - Resource Family Visit Record
• RFA 809C (12/23) - Resource Family Visit – Corrective Action Plan
• RFA 811 (8/17) - Confidential Names
• RFA 812 (6/17) - Detail Supportive Information
• RFA 9099 (9/23) - Complaint Investigation Report
• RFA 9099C (9/23) - Complaint Investigation Report - Continued
• RS 3 (5/03) - Service Provider Referral/Notification Form
• RS 36 (10/03) - Employment And Training Requirements For Refugee Cash Assistance(RCA)

S Forms

• SAR 2 (6/19) - Reporting Changes For Cash Aid And CalFresh
• SAR 2LP (6/19) - Reporting Changes For Cash Aid and CalFresh (20pt Font)
• SAR 3 (2/15) - Mid-Period Status Report For Cash Aid and CalFresh
• SAR 7 (12/23) - SAR 7 Eligibility Status Report
• SAR 7 Addendum (4/13) - Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFresh
• SAR 7A (12/23) - How To Fill Out Your SAR 7 Eligibility Status Report
• SAR 7AB (12/23) - How To Fill Out Your SAR 7 Eligibility Status Report - Blank
• SAR 7B (12/23) - SAR 7 Eligibility Status Report - Blank
• SAR 7 DA (12/23) - Domestic Abuse Addendum to the SAR 7
• SAR 22 (3/13) - Sponsored NonCitizens Applying For Or Receiving Cash Aid and/or CalFresh
• SAR 23 (3/13) - Senior Parent Statement Of Facts
• SAR 72 (3/13) - Sponsor's Semi-Annual Income And Resources Report
• SAR 73 (3/13) - Senior Parent Semi-Annual Income Report
• SAR 90 (1/14) - Reminder Letter
• SAWS 1 (8/13) - Initial Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs
• SAWS 2 PLUS (4/15) - Application For CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs
• SAWS 30 (3/19) - Notification Of New Employment
• SAWS 2A SAR (4/15) - Rights and Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, And/Or Medi-Cal/34-County Medical Services Program (CMSP)
• SNB 1 (8/18) - Notice To CalFresh Recipients Supplemental Nutrition Benefit (SNB) Program
• SNB 2 (8/18) - Notice Of Approval For Supplemental Nutrition Benefit (SNB) Program
• SNB 3 (8/18) - Notice Of Change For Supplemental Nutrition Benefit (SNB) Program
• SNB 4 (8/18) - Notice Of Expiration Of Certification For Supplemental Nutrition Benefit (SNB) Program
• SNB 5 (8/18) - Notice Of Discontinuance For Supplemental Nutrition Benefit (SNB) Program
• SNB 7 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Receiving Intercounty Transfer
• SNB 8 (6/19) - CalFresh And Supplemental Nutrition Benefit (SNB) Informing Notice Of Sending Intercounty Transfer
• SOC 111 (8/24) – Coversheet Cash Assistance Program for Immigrants (CAPI) Redetermination Form
• SOC 295 (9/18) - Application For In-Home Supportive Services (14pt Font)
• SOC 295L (9/18) – Application For In-Home Supportive Services (18pt Font)
• SOC 310 (1/03) - Statement of Facts For In-Home Supportive Services
• SOC 321 (11/99) - Request For Order And Consent - Paramedical Services
• SOC 332 (9/09) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist)
• SOC 332L (1/19) - In-Home Supportive Services (Recipient/Employer Responsibility Checklist)
• SOC 341 (2/24) - Report Of Suspected Dependent Adult/Elder Abuse
• SOC 341A (2/24) - Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders
• SOC 404 (10/11) - In-Home Supportive Services Program Direct Deposit Enrollment/Change/Cancellation Form
• SOC 409 (7/03) - IHSS/CMIPS Elective State Disability Insurance (SDI) Form
• SOC 426 (6/16) - In-Home Supportive Services (IHSS) Program Provider Enrollment Form
• SOC 426A (1/16) - In-Home Supportive Services (IHSS) Program Recipient Designation Of Provider
• SOC 426C (10/10) - In-Home Supportive Services (IHSS) Program California Code Sections
• SOC 445 (6/99) - Medi-Cal Recovery For The Personal Care Services Program
• SOC 450 (2/23) - Voluntary Services Certification
• SOC 453 (8/22) - Cash Assistance Program For Immigrants (CAPI) Statement Of Household Expenses And Contributions
• SOC 455 (1/99) - Authorization for State Reimbursement of Interim Assistance
• SOC 600 (4/24) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider CalSavers Payroll Deduction Authorization / Change / Cancellation Form
• SOC 804 (2/20) - Statement Of Facts For Determining Continuing Eligibility For The Cash Assistance Program For Immigrants (CAPI)
• SOC 809 (10/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Statement
• SOC 814 (12/20) - Statement Of Facts Cash Assistance Program For Immigrants (CAPI)
• SOC 821 (3/06) - Assessment Of Need For Protective Supervision For In-Home Supportive Services Program
• SOC 825 (6/06) - Protective Supervision 24-Hours-A-Day Coverage Plan
• SOC 827 (12/06) - In-Home Supportive Services (IHSS) Program - Individual Emergency Back-Up Plan
• SOC 829 (10/18) - In-Home Supportive Services (IHSS) / Waiver Personal Care Services (WPCS) Provider Direct Deposit Enrollment/Change/Cancellation Form
• SOC 830 (9/22) - Request for Conditional CAPI After Naturlization Pending SSI/SSP Eligiblity Determination
• SOC 831 (10/18) - IHSS Provider Letter
• SOC 832 (1/13) - Notice of Child Abuse Central Index Listing
• SOC 834 (3/13) - Request for Grievance Hearing
• SOC 838 (10/12) - In-Home Supportive Services (IHSS) Recipient Request For Assignment Of Authorized Hours To Providers
• SOC 839 (6/23) - In-Home Supportive Services (IHSS) Designation Of Authorized Representative
• SOC 839A (6/23) - In-Home Supportive Services (IHSS) Designation of Signatory for TPRD
• SOC 839B (6/23) - In-Home Supportive Services (IHSS) Cancellation of Authorized Representative-TPRD Signatory
• SOC 840 (10/12) - In-Home Supportive Services (IHSS) Program Provider Or Recipient Change Of Address And/Or Telephone
• SOC 846 (10/19) - In-Home Supportive Services (IHSS) Program Provider Enrollment Agreement
• SOC 847 (5/16) - Important Information For Prospective Providers About The In-Home Supportive Services (IHSS) Program Provider Enrollment Process
• SOC 848 (2/20) - In-Home Supportive Services Program Notice Of Provider Eligibility
• SOC 848A (5/16) - In-Home Supportive Services Program Lapse of Ten-Year Timeframe for Tier 2 Crime
• SOC 849 (9/22) – In-House Supportive Services Program Notice Of Incomplete Provider Enrollment Form
• SOC 850 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility
• SOC 851 (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Provider Ineligibility Incomplete Provider Process
• SOC 851A (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Incomplete Provider Process 15-Day Notification
• SOC 852 (1/11) - In-Home Supportive Services Program Notice Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Of Supportive Services Program)
• SOC 852A (5/16) - IHSS Program Notice To Provider Applicant Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies)
• SOC 853 (10/09) - In-Home Supportive Services Program Notice Of Provider Ineligibility
• SOC 854 (1/11) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility
• SOC 854L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Eligibility
• SOC 855 (5/16) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process
• SOC 855L (10/18) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process
• SOC 855A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program)
• SOC 855AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes (Elder Or Dependent Adult Abuse/Child Abuse & Fraud Against A Government Health Care Or Supportive Services Program)
• SOC 855B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies)
• SOC 855BL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes (Serious/Violent Felonies; Sex Offender Felonies; Fraud Against Government Agencies)
• SOC 856 (1/12) - To Request Appeal Of Provider Enrollment Denial
• SOC 856L (1/19) - To Request Appeal Of Provider Enrollment Denial
• SOC 857 (5/16) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver
• SOC 857L (10/18) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver
• SOC 857A (4/12) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver
• SOC 857B (6/16) - In-Home Supportive Services Program Notice To Provider Of Provider Ineligibility Criminal Background Check Needed
• SOC 858 (12/11) - In-Home Supportive Services Provider Notification
• SOC 858A (1/11) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction
• SOC 857AL (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider Ineligibility Acknowledgement Of Receipt Of Invalid Request For Provider Waiver
• SOC 858B (5/16) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction
• SOC 859A (1/11) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction
• SOC 859AL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 1 Crimes Ineligibility - Subsequent Conviction
• SOC 859B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction
• SOC 859BL (10/18) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction
• SOC 860 (7/18) - Sponsor's Statement Of Facts Income And Resources
• SOC 861 (10/10) - Safely Surrendered Baby Medical Questionnaire
• SOC 862 (5/16) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver
• SOC 862L (10/18) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver
• SOC 863 (5/19) - In-Home Supportive Services (IHSS) Applicant Provider Request For General Exception
• SOC 864 (3/11) - In-Home Supportive Services (IHSS) Program Individualized Back-up Plan and Risk Assessment
• SOC 865 (7/12) - IHSS Request For Applicant Provider Reference
• SOC 865L (10/18) - IHSS Request For Applicant Provider Reference
• SOC 870 (5/16) - In-Home Supportive Services Program (IHSS) Notice To Provider Of Provider Eligibility Acknowledgment Of Receipt Of Waiver
• SOC 873 (10/16) - In-Home Supportive Services (IHSS) Program Health Care Certification Form
• SOC 873L (1/19) - In-Home Supportive Services (IHSS) Program Health Care Certification Form (Large Print)
• SOC 874 (10/16) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement
• SOC 874L (1/19) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement
• SOC 875 (7/11) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Medical Certification Requirement
• SOC 875L (10/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Health Care Certification Requirement
• SOC 876 (4/23) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted
• SOC 876L (10/18) - In-Home Supportive Services (IHSS) Program Notice Of Provisional Approval Health Care Certification Exception Granted
• SOC 885 (6/13) - In-Home Supportive Services (IHSS) Program Notice Of Denial Of Request For In-Home Reassessment Based On State Law Change
• SOC 887A (12/20) - Cash Assistance Program For Immigrants (CAPI) Nonmedical Out-Of-Home Care (NMOHC) Payment Standard Eligibility Determination - Retroactive Certification of NMOHC Payment Standard Eligibility
• SOC 2255 (3/19) - In-Home Supportive Services (IHSS) Program Provider Workweek & Travel Time Agreement
• SOC 2256 (11/15) - In-Home Support Services Program Recipient And Provider Workweek Agreement
• SOC 2257 (12/17) - In-Home Supportive Services Program Notice To Provider Of Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2257A (12/17) - In-Home Supportive Services Program Notice To Recipient Of Provider’s First/Second Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2257B (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation No Record Of Completion Of Review Of Instructional Materials
• SOC 2257C (3/16) - In-Home Supportive Services Program Notice To Provider Of Second Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2258 (3/16) - In-Home Supportive Services Program Notice To Provider Of Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2258A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2259 (3/16) - In-Home Supportive Services Program Notice To Provider Of Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2259A (3/16) - In-Home Supportive Services Program Notice To Recipient Of Provider’s Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2263 (3/16) In-Home Supportive Services Program Notice To Provider Rescinding Violation
• SOC 2264 (3/16) In-Home Supportive Services Program Notice To Recipient Rescinding Provider Violation
• SOC 2265 (3/16) - In-Home Supportive Services Program Notice To Provider Reduction Of Total Violation Count
• SOC 2266 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval Of Exception To Exceed Weekly Hours
• SOC 2266A (1/16) - In-Home Supportive Services Program Notice To Provider Approval Of Exception To Exceed Weekly Hours
• SOC 2267 (1/16) - In-Home Supportive Services Program Notice To Recipient Denial Of Exception To Exceed Weekly Hours
• SOC 2267A (1/16) - In-Home Supportive Services Program Notice To Provider Denial Of Exception To Exceed Weekly Hours
• SOC 2268 (1/16) - In-Home Supportive Services Program Notice To Recipient Approval For Provider To Work Alternate Schedule Due To Recurring Event
• SOC 2268A (1/16) - In-Home Supportive Services Program Notice To Provider Approval To Work Alternate Schedule Due To Recurring Event
• SOC 2269 (1/16) In-Home Supportive Services Program Notice To Recipient Cancellation Of Alternate Schedule Due To Recurring Event
• SOC 2269A (1/16) In-Home Supportive Services Program Notice To Provider Cancellation Of Alternate Schedule Due To Recurring Event
• SOC 2270 (2/16) In-Home Supportive Services Program Notice To Recipient Failure To Complete Workweek Agreement (SOC 2256)
• SOC 2270A (1/16) In-Home Supportive Services Program Notice To Provider Failure To Complete Workweek And Travel Agreement (SOC 2255)
• SOC 2271 (3/21) - In-Home Supportive Services (IHSS) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours
• SOC 2271A (11/15) - In-Home Supportive Services (IHSS) Program Recipient Notice Of Maximum Weekly Hours
• SOC 2272 (7/16) In-Home Supportive Services Program Notice To Provider Of Right To Dispute Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2272A (4/16) - In-Home Supportive Services Program Notice To Provider Acknowledgement Of Receipt Of County Violation Review
• SOC 2272B (4/16) - In-Home Supportive Services Program Notice To Recipient Acknowledgement Of Provider's Request For County Violation Review For Exceeding Workweek And/or Travel Time Limits
• SOC 2273 (11/18) In-Home Supportive Services Program State Administrative Review Request Of Third Or Fourth Violation For Exceeding
• SOC 2280 (6/16) In-Home Supportive Services Program Notice To Provider Upholding First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2281 (6/16) In-Home Supportive Services Program Notice To Recipient Upholding Provider’s First Or Second Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2282 (9/18) In-Home Supportive Services Program Notice To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2283 (9/18) In-Home Supportive Services Program Notice To Recipient Upholding Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2286 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2287 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Provider’s Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
• SOC 2288 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Rescinding Third Violation Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2289 (7/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Rescinding Provider’s Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits
• SOC 2290 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Provider Upholding Fourth Violation (One-Year Period Of Ineligibility)
• SOC 2291 (6/16) In-Home Supportive Services Program State Administrative Review Request Response Letter To Recipient Upholding Fourth Violation (One-Year Period Of Ineligibility)
• SOC 2292 (1/19) - In-Home Supportive Services Program Notice To Provider Of Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272)
• SOC 2293 (1/19) - In-Home Supportive Services Program Notice To Recipient Of Provider's Failure To Timely Or Completely Submit The Right To Dispute Violation For Exceeding Workweek And/or Travel Time Limits Form (SOC 2272)
• SOC 2298 (1/19) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Form For Federal And State Tax Wage Exclusion
• SOC 2299 (1/19) - In-Home Supportive Services (IHSS) Program And Waiver Personal Care Services (WPCS) Program Live-In Self-Certification Cancellation Form For Federal And State Tax Wage Exclusion
• SOC 2300 (2/17) - In-Home Supportive Services Program Notice To Applicant Of Application Confirmation Number
• SOC 2301 (4/17) - In-Home Supportive Services (IHSS) Or Waiver Personal Care Services (WPCS) Recipient Confirmation Of Enrollment In Electronic Timesheet Service Or Telephone Timesheet System
• SOC 2302 (5/19) - In-Home Supportive Services (IHSS) Program Provider Paid Sick Leave Request Form
• SOC 2303 (12/19) - In-Home Supportive Services Program Notice To Provider Of Incomplete Paid Sick Leave Request Form (SOC 2302)
• SOC 2305 (8/19) - In-Home Supportive Services (IHSS) Program Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2)
• SOC 2306 (1/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Referral Justification
• SOC 2307 (1/18) - In-Home Supportive Services (IHSS) Program Extraordinary Circumstances Secondary Evaluation Worksheet
• SOC 2308 (2/18) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances Approved Exemption Provider Agreement
• SOC 2309 (2/18) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances
• SOC 2309A (2/18) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Approval Of Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances
• SOC 2310 (5/19) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Ineligibility For Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances
• SOC 2310A (5/19) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Ineligibility For Exemption From The In-Home Supportive Services Program Workweek Limits For Extraordinary Circumstances
• SOC 2311 (2/18) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (SOC 2308)
• SOC 2312 (3/20) - In-Home Supportive Services (IHSS) Program Notice To Provider Of Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In Eligibility
• SOC 2312A (3/20) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Termination Of Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) Due To A Change In Eligibility
• SOC 2313 (3/20) - In-Home Supportive Services (IHSS) Program Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) State Administrative Review Request Form
• SOC 2323 (12/18) - In-Home Supportive Services Program – Provider Requirements For Minor Recipients Living With Their Parents
• SOC 2325 (9/19) - In-Home Supportive Services Program Notice To Provider Of Non-Acceptance Of Subsequent Request For Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2)
• SOC 2326 (10/19) - In-Home Supportive Services (IHSS) Recipient’s Responsibility To Stop Sexual Harassment In The Workplace
• SOC 2327 (10/19) - In-Home Supportive Services (IHSS) Provider’s Right To File A Sexual Harassment Complaint
• SSGP 2 (8/24) - CDSS Disaster Recovery Program (SSGP FAQ)
• SSGP 45 (5/24) - The State Supplemental Grant Program (SSGP)
• SSP 14 (9/10) - Authorization For Reimbursement Of Interim Assistance Initial Claim Or Posteligibility Case
• SSP 18 (3/24) - Notice Of Action And Right To Request A State Hearing On Interim Assistance

T Forms

• TEMP 2177 (11/99) - CFAP Work Rule
• TEMP 2201 (7/02) - Cash Aid/Food Stamp Electronic Benefit Transfer - EBT Request For A Designated Alternate Card Holder/Authorized Representative
• TEMP 2202 (7/02) - Cash Aid/Food Stamp Electronic Benefit Transfer - EBT Service Request
• TEMP 2203 (7/02) - Request For Cash Aid Electronic Benefit Transfer - EBT Exemption
• TEMP 2206 (4/02) - Notice Of Action
• TEMP 2207 (5/02) - Notice Of Action
• TEMP 2208 (4/02) - Notice Of Action
• TEMP 2209 (4/02) - Notice Of Action
• TEMP 2211 (4/02) - Notice Of Action
• TEMP 2212 (5/02) - Notice Of Action
• TEMP 2214 (7/08) - Additional Information About Electric Benefit Transfer (EBT)
• TEMP 2229 (3/07) ENG/CH - Important Notice - KinGAP Informing Notice
• TEMP 2232 (4/08) - Notice of Possible Listing on the Child Abuse Central Index
• TEMP 2250 (6/24) - State Law Changes Maximum Aid Payment (MAP) Levels For Cash Aid Recipients
• TEMP 2252 (12/20) - State Law Changes The CalWORKs Earned Income Disregard - Use Starting June 1, 2021
• TEMP 2252 (3/22) - State Law Changes The CalWORKs Earned Income Disregard - Use Starting June 1, 2022
• TEMP 2260 (8/16) Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Maximum Family Grant (MFG) Rule
• TEMP 2316 (5/22) - Sick Leave Yearly Notifications
• TEMP 3005 (12/14) - Changes For People With A Prior Felony Drug Conviction
• TEMP 3010 (5/18) Important Information For In-Home Supportive Services Recipients About The New Paid Sick Leave Program
• TEMP 3011 (1/24) – Child and Family Team (CFT) & Child and Adolescent Needs and Strengths Tool (CANS) - For Parents
• TEMP 3012 (1/24) – Child and Family Team CFT and CANS - For Youth
• TEMP 3013 (1/24) – Child and Family Team (CFT) & Child and Adolescent Needs and Strengths Tool (CANS) - For Professionals
• TEMP 3014 - (9/19) Treasury Offset Program (TOP) Pre-Offset Notice - Use Until 12/20
• TEMP 3014 - (2/20) Treasury Offset Program (TOP) Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3015 - (2/20) Franchise Tax Board (FTB) Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3015A (2/20) - Franchise Tax Board (FTB) Annual Pre-Offset Notice - Do Not Use Until 12/20
• TEMP 3016 - Chinese
• TEMP 3017 - (2/20) - Treasury Offset Program Notification Of Offset
• TEMP 3022 - (8/21) - Important Information For CalWORKs Families -State Law Increases The CalWORKs Time Limit To 60 Months
• TEMP CF 1468 (2/15) - CalFresh Notice Of Change
• TEMP CW 101 (1/99) - CalWORKs Immunization Rules
• TEMP CW 2225 (10/20) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Child Support Disregard/Pass-Through Rules
• TEMP M40-107A (9/11) - CalWORKs 48-Month Time Limit Time On Aid (Unticking Months Due To Temporary Exemptions)
• TEMP M40-107E (4/11) - Change CalWORKs Time Limit 48th Month On Aid
• TEMP M40-107G (4/11) - Discontinue CalWORKs Time Limit/Income Exceeds
• TEMP M40-107H (4/11) - Change CalWORKs Time Limt 40th Month On Aid-MFG Child
• TEMP M40-107I (4/11) - Discontinue CalWORKs Time Limit 48th Month On aid, No Eligible Child
• TEMP M40-107J (4/11) - Partial Approval CalWORKs Time Limit Timed-Out Adult
• TEMP NA 303B (4/00) - Notice Of Action (Continued)
• TEMP NA 820A (5/02) - Notice Of Action
• TEMP NA 1221 (2/01) - Retroactive Approval Dominika V. Saenz
• TEMP NA 1222 (2/01) - Change Dominika V. Saenz
• TEMP NA 1225 (9/01) - Underpayment Computation
• TEMP NA 1228 (6/01) - Notice Of Action
• TEMP NA 1229 (6/01) - Notice Of Action
• TEMP NA 1232 (6/11) - Notice of Action - CalFresh EBT Account
• TEMP NA 1238 (4/23) – CalFresh Notice Of Action EBT Account Adjustment
• TEMP W&I 11450.025 (5/11) - Incremental Grant Reduction
• TEMP W&I 11450.025A (5/11) - Incremental Grant Reduction
• TEMP WI 10072 (8/13) - EBT Replacement Approval
• TEMP WI 10072A (8/13) - EBT Replacement Review
• TILP 1 (1/23) - Transitional Independent Living Plan & Agreement
• TM44-111A - (4/13) - Income Disregards Change
• TM44-314 (8/16) - Basic Approval
• TM44-315D (4/11) - 8 Percent Grant Reduction Change
• TM44-315E (4/11) - Grant Reduction And Income Disregard Discontinue
• TM44-315F (4/11) - Grant Reduction And Income
• TM44-315G (12/13) - Law Change To MAP Levels
• TM44-315H (9/14) - Law Change To MAP Levels
• TM44-315I (8/16) - Law Change to MAP levels
• TM44-315K (7/19) - Law Change To MAP Levels
• TM44-315M (7/22) - Law Change To MAP Levels
• TM44-315N (7/23) - Law Change To MAP Levels
• TM82-832 (12/14) - Basic Approval
• TNB 1 (8/18) - Notice To CalFresh Recipients Transitional Nutrition Benefit (TNB) Program
• TNB 2 (8/18) - Notice Of Approval For Transitional Nutrition Benefit (TNB) Program
• TNB 3 (8/18) - Notice Of Change For Transitional Nutrition Benefit (TNB) Program
• TNB 4 (8/20) - Notice Of Recertification For Transitional Nutrition Benefit (TNB) Program
• TNB 5 (8/18) - Recertification Reminder Notice For Transitional Nutrition Benefit (TNB) Program Recertification Form Not Received Or Incomplete
• TNB 6 (8/18) - Notice Of Discontinuance For Transitional Nutrition Benefit (TNB) Program
• TNB 7 (6/19) - Transitional Nutrition Benefit (TNB) Informing Notice Of Receiving Intercounty Transfer
• TNB 8 (6/19) - Transitional Nutrition Benefit (TNB) Informing Notice Of Sending Intercounty Transfer

W Forms

• Welfare to Work Handbook
• WI 10072A (10/23) - EBT Replacement Approval
• WI 10072B (10/23) - EBT Replacement Review
• WINS 1 (5/14) - Notice To All CalFresh Recipients Work Incentive Nutritional Supplement (WINS) Benefit Important - Please Read
• WINS 1239 (5/14) - CalFresh Notice Of Approval/Denial/Termination Work Incentive Nutritional Supplement (WINS) Benefits
• WTW 1 (12/05) - Welfare To Work Plan Rights and Responsibilities
• WTW 2 (6/24) - Welfare To Work Plan Activity Assignment
• WTW 4 (8/04) - Notice to Other Parent
• WTW 4A (4/24) - Notice to Other Parent - Use Starting January 1, 2025
• WTW 5 (5/23) - Welfare-To-Work Program Notice
• WTW 8 (6/04) - Student Financial Aid Statement Welfare to Work Supportive Services
• WTW 9 (7/99) - Welfare to Work Appraisal Appointment Letter
• WTW 10(07/99) - Request For Welfare to Work Third Party Assessment
• WTW 11 (7/99) - Welfare to Work/Cal-Learn Supportive Service Overpayment/Underpayment Notice
• WTW 12 (7/99) - Welfare to Work/Cal-Learn Supportive Service Repayment Agreement
• WTW 13 (7/99) - Welfare to Work/Cal-Learn Supportive Service Overpayment Final Notice
• WTW 15 (9/13) - Simplified CalFresh Program Unpaid Work Experience (WEX) And Unpaid Community Service Hours Worksheet
• WTW 16 (12/05) - Grant-Based On-The Job Training Participation: Voluntary Consent Form
• WTW 16A (6/06) - Examples Of Family Income (Region 1)
• WTW 16A (12/20) - Grant-Based OJT Income Examples For Region 1 - Use Starting June 1, 2021
• WTW 16A (3/22) - Grant-Based OJT Income Examples For Region 1 - Use Starting June 1, 2022
• WTW 16B (6/06) - Examples Of Family Income (Region 2)
• WTW 16B (12/20) - Grant-Based OJT Income Examples For Region 2 - Use Starting June 1, 2021
• WTW 16B (3/22) - Grant-Based OJT Income Examples For Region 2 - Use Starting June 1, 2022
• WTW 17 (12/15) - Waiver Of CalWORKs Learning Disabilities Screening And/Or Evaluation
• WTW 20 (12/05) - Permission To Release Learning Disabilities Information
• WTW 26 (8/15) - Good Cause Determination Guidelines
• WTW 27 (10/03) - Request For Good Cause Determination
• WTW 29 (8/15) - Plan To Meet Welfare To Work Rules And Get My Cash Aid Back
• WTW 31 (8/15) - Request To Meet Welfare To Work Rules To Get My Cash Aid Back
• WTW 32 (10/03) - Welfare To Work Compliance Plan
• WTW 34 (1/24) - Welfare To Work Family Reunification Plan - Use Starting January 1, 2025
• WTW 37 (7/09) - Permission To Release Domestic Abuse Information When Moving To Another County
• WTW 38 (6/13) - Welfare-To-Work 24-Month Time Clock Notice
• WTW 43 (9/14) Notice Of Your Welfare-To-Work (WTW) 24-Month Time Clock Ending Soon
• WTW 44 (1/15) – Welfare To Work (WTW) 24-Month Time Clock Extension Request Form
• WTW 45 (1/15) – Welfare To Work (WTW) 24-Month Time Clock Extension Determination
• WTW 46 (1/15) - End Of Welfare-To-Work 24-Month Time Clock Review Appointment Letter
• WTW 47 (3/15) - Online CalWORKs Appraisal Tool Rights And Privacy
• WTW 51 (1/21) - Welfare To Work Noncompliance Checklist Tool - Use Starting May 1, 2022
• WTW 246 (11/20) - Employment Workshop & Job Search Notice
• WTW 2490 (11/20) - Non-Receipt Of WTW Attendance/Progress Report
• WTW EOA 1 (11/17) - CalWORKs Educational Opportunity and Attainment (EOA) Program Application Form
• WTW EOA 2 (12/17) - CalWORKs Educational Opportunity and Attainment (EOA) Program Approve Form
• WTW EOA 3 (12/17) - Notice of Action CalWORKs Educational Opportunity and Attainment (EOA) Program Deny Form