2011 Notice Of Forms Changes

11-161
KG 1 (12/11)  Kin-GAP Mutual Agreement for 18 year olds

11-160
SOC 369A (11/11)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment

11-159
PUB 428 (11/11) English and Spanish - It's Your Money - Claim It and Save It - Brochure
PUB 429 (11/11) English and Spanish - It's Your Money - Claim It and Save It - Flyer

11-158
SOC 875 (11/11) IHSS Program Notice To Recipient Of Health Care Certification Requirement

11-157
SOC 874 (11/11) IHSS Program Notice To Applicant Of Health Care Certification Requirement

11-156
SOC 873 (11/11) IHSS Program Health Care Certification Form

11-155
TEMP 2257 (11/11) IHSS Program Notice To Recipient Of Reduction In Authorized Hours

11-154
TEMP 2256 (11/11)  IHSS Program Notice To Recipient Of Exemption From Reduction In Service Hours

11-153
LIC 422 (9/11)  Notice of Civil Penalties Due

11-152
SOC 877 (11/11)  In-Home Supportive Services (IHSS) Program Application For Supplemental Care

11-151
AAP 5 (11/11)  Adoption Assistance Program Independent Adoptions Program Statement of Acknowledgement

11-150
CW 86 (9/11) English and Spanish - Agreement-Restricted Account CalWORKs Program

11-149
SOC 880 (11/11) Safely Surrendered Baby - Report To The California Department Of Social Services

11-148
SOC 163 (11/11)  Voluntary Re-Entry Agreement For Extended Foster Care

11-147
SOC 162 (10/11)  Mutual Agreement For Extended Foster Care 

11-146
SOC 161 (9/11)  Six-Month Certification Of Extended Foster Care Participation

11-145
AD 927 (9/11)  Statement of Understanding - Independent Adoptions Program -- Indian Child

11-144
SOC 369A (10/11) Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment

11-143
LIC 602A (8/11)  Physician's Report For Residential Care Facilities For The Elderly (RCFE)

11-142
PUB 456 (3/11)  English and Spanish - Important Information For Relatives

11-141
SOC 876 (10/11) IHSS Program Notice Of Provisional Approval Health Care Certification Exception Granted

11-140
PUB 411 (8/11) - 20 Facts About Child Abuse And Neglect (paper size 9" x 12" printed landscape)

11-139
LIC 9200 (9/11)  Pre-Licensing Facility Evaluation Checklist

11-138
LIC 9020 (8/11)  Register of Facility Clients/Residents

11-137
LIC 195A (8/11)  Notice of Operation In Violation Of Law - Family Child Care Home

11-136
LIC 195 (8/11) Notice Of Operation In Violation Of Law

11-135
NA 1263 (8/11) English and Spanish - Notice Of Action - Overissuance Budget Worksheet

11-134
SOC 858 (9/11) English and Spanish IHSS Provider Notification

11-133
SOC 831 (10/11) IHSS Provider Letter

11-132
SOC 829 (10/11) IHSS Provider Direct Deposit Enrollment/Change/Cancellation Form

11-131
SOC 404 (10/11) English and Spanish IHSS Program Direct Deposit Enrollment/Change/Cancellation Form

11-130
QR 377.2 (10/11) CalFresh Notice Of Expiration Of Certification

11-129
DFA 387 (10/11) CalFresh Request For Information

11-128
DFA 386 (10/11) CalFresh Notice Of Missed Interview

11-127
DFA 1239 (10/11) CalFresh Notice Of Approval/Denial/Termination Transitional Benefits

11-126
FS 29 (10/11) CalFresh Recertification Appointment Letter

11-125
TEMP WTW 5 (8/11) Welfare-To-Work Progam Notice

11-124
TEMP CW 2186C (8/11) English and Spanish - CalWORKs Exemption Request For Welfare-To-Work Teen Parents

11-123
TEMP M42-769 (8/11) English and Spanish - Approve School Bonus

11-122
TEMP CL 10 (8/11) English and Spanish - Welfare-to-Work Teen Parent Notice Of Exemption

11-121
TEMP CL 8 (8/11) English and Spanish - Welfare-To-Work Teen Parent Notice Of Report Card Submittal Schedule

11-120
TEMP CL 4 (8/11) English and Spanish - Welfare-To-Work Teen Parent Informing Notice To Parent/Legal Guardian Of Welfare-To-Work Participant

11-119
TEMP CL 2 (8/11) English and Spanish - Welfare-To-Work Program Requirements

11-118
TEMP CL 1 (8/11) English and Spanish - Welfare-To-Work Program Information Orientation Appointment Notice

11-117
WTW 15 (9/11) Simplified Food Stamp Program Unpaid Work Experience

11-116E
SAWS 2A QR (9/11) Rights, Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, and/or Medi-Cal/34-County Medical Services Program

11-116
SAWS 2A QR (9/11) Rights, Responsibilities And Other Important Information For The Cash Aid And CalFresh Programs, and/or Medi-Cal/34-County Medical Services Program

11-115
CW 2166 (9/11) Multilingual Work Really Pays! Here's How - Work Pays Notice

11-114
NA 200 (9/11) Notice Of Action - Multipurpose - Incl Budget

11-113
NA 271 (9/11) Notice Of Action - Family's Income

11-112
NA 300 (9/11) Notice Of Action - Recipient - Financial Eligibility Tests

11-111
NA 531 (9/11) Notice Of Action 48-Month Time Limit (Continued) Adult Reached CalWORKs 48-Month Time Limit

11-110
NA 1239 (9/11) Notice Of Action Continued Quarterly Reporting Budget

11-109
QR 30 (9/11) CalWORKs Budget Worksheet

11-108
TEMP NA BACK (9/11) Your Hearing Rights

11-107
AAP 8 (7/11) English and Spanish - Adoptions Assistance Program Nonrecurring Adoption Expenses Agreement

11-106
AD 521 (8/11) Application For Adoption Of A Child

11-105
AD 904 (7/11) English and Spanish - Consent For Contact

11-104
AD 929 (8/11) Waiver Of Right To Revoke Consent Independent Adoption Program

11-103
AD 4320 (8/11) Adoption Assistance Program (AAP) Agreement

11-102
DFA 385 (9/11) Application For Disaster CalFresh
DFA 390 (9/11) Notice Of Approval/Denial  For Disaster CalFresh

11-101
FS 11 (9/11) ENG/SP Notice To All CalFresh Recipients Important - Please Read

11-100
AD 930 (7/11) Independent Adoption Placement Agreement Transmittal

11-099 
LIC 602 (7/11) Physician's Report For Community Care Facilities

11-098
FC 8 (7/11)  Federal Eligibility Certification For Adoption Assistance Program

11-097
AAP 4 (7/11)  Eligibility Certification Adoption Assistance Program 

11-096
AAP 3 (7/11)  Reassessment Information Adoption Assistance Program

11-095
AAP 2 (7/11)  Payment Instructions Adoption Assistance Program
AAP 6 (7/11)  Adoption Assistance Program Negotiated Benefit Amount and Approval

11-094
LIC 9163B  (7/11)  Request For Live Scan Service - Long Term Care Ombudsman

11-093
PUB 13 (6/11)  Eng/SP   Your Rights Pamphlet (Requires 8 1/2" x 14" paper printed landscape)

11-092
LIC 422A (7/11)  Civil Penalty Ledger

11-091
LIC 422 (7/11)  Notice of Civil Penalties Due

11-090
LIC 421C (7/11)  Civil Penalty Assessment - Immediate $150

11-089
LIC 421A (7/11)  Civil Penalty Assessment (Unlicensed Facility)

11-088
LIC 421 (7/11)  Civil Penalty Assessment
LIC 421B (7/11)  Civil Penalty Assessment - Immediate

11-087
LIC 178 (7/11)  Penalty Review

11-086
QR 285B (8/11) CalFresh Budget Worksheet/Quarterly Reporting Households
DFA 285B (8/11) CalFresh Budget Worksheet/Change Reporting Household
DFA 285D (8/11) CalFresh Budget Worksheet - Special Medical/Shelter Deductions

11-085
DFA 377.7D3 (6/11) English and Spanish - CalFresh Overissuance Notice For Administrative Errors Only

11-084
PUB 275 (4/07) Family Planning - Making The Commitment For A Healthy Future

11-083
PUB 111 (8/11) Deaf Access Program Brochure

11-082
SOC 873 (7/11) IHSS Program Medical Certification Form
SOC 874 (7/11) IHSS Program Notice To Applicant Of Medical Certification Requirement
SOC 875 (7/11) IHSS Program Notice To Recipient Of Medical Certification Requirement

11-081
TEMP CW 2186A (7/11) CalWORKs Time Limit And Welfare-To-Work Participation Exemption Request Form

11-080
CW 2184 (7/11) CalWORKs 48-Month Time Limit

11-079
SOC 831 (7/11) IHSS Provider Letter

11-078
CW 2186B (4/11) English and Spanish - CalWORKs and Welfare To Work Time Limit Exemption Determination

11-077
NA 835 (4/11) English and Spanish - Notice Of Action Child Care Discontinuance

11-076
NA 1267 (4/11) CalFresh Informing Notice Of Receiving Intercounty Transfer
NA 1268 (4/11) CalFresh Informing Notice Of Sending Intercounty Transfer

11-075
CW 101 (6/11) English and Spanish - CalWORKs Immunization Rules

11-074
WTW 16B (6/11) Grant-Based OJT Income Examples For Region 2

11-073
WTW 16A (6/11) Grant-Based OJT Income Examples For Region 1

11-072
NA 281A (6/11) Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 7-1-2011)

11-071
NA 281 (6/11) Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 1-1-98 thru 6-30-2011)

11-070
NA 274F (6/11) Notice Of Action Overpayment Amount Owed (For Overpayments Occurring On Or After 7-1-2011)

11-069
NA 274E (6/11) Notice Of Action Overpayment Amount Owed (For Overpayments Occurring On Or After 1-1-98 through 6-30-2011)

11-068
CW 2192 (6/11) Tracking Non-California TANF Assistance For Time Limits

11-067
CW 2191 (6/11) Time On Aid Verification For CalWORKs/TANF 48-Month Time Limits

11-066
CW 2190B (6/11) CalWORKs 48-Month Time Limit Extender Determination Denial Form

11-065
CW 2190A (6/11) CalWORKs 48-Month Time Limit Extender Request Form

11-064
CW 2189 (6/11) Notice Of Your CalWORKs Time Limit - 42nd Month On Aid

11-063
CW 88 (6/11) Diversion Services Agreement CalWORKs Program

11-062
CW 88 Coversheet (6/11) You May Be Eligible For Diversion Services

11-061
TEMP NA 1232 (6/11) CalFresh Notice Of Action - EBT Account

11-060
FS 27 (3/10) Non-Assistance Food Stamps (NAFS) Household Recertification Form

11-059
CW 2184 (4/11) CalWORKs 48-Month Time Limit On Aid
CW 2187 (4/11) Your CalWORKs 48-Month Time Limit/Information About Your CalWORKs 48-Month Time Clock
TEMP CW 2186A (4/11) CalWORKs Time Limit and Welfare-To-Work Participation Exemption Request Form

11-058
NA 530 (4/11) Notice of Action - 48-Month Time Limit
NA 531 (4/11) Notice of Action - Adult Reached CalWORKs 48-Month Time Limit (Continued)
NA 532 (4/11) Notice of Action - 48-Month Time Limit (Continued) Adult Reached CalWORKs 48-Month Time Limit - Discontinue

11-057
NA BACK 9 (Revised 4/2011)  English and Spanish Your Hearing Rights

11-056
TEMP 2253 (4/11) You Are Required To Participate In Welfare-To-Work
TEMP 2254 (4/11) State Law Has Changed The Cal-Learn Program New Rules

11-055
TEMP 2251 (4/11) English and Spanish New State Law Rules In CalWORKs Starting July 1, 2011

11-054
AAP 8 (1/11) Adoptions Assistance Program Nonrecurring Adoption Expenses Agreement

11-053
TEMP CW 2185 (2/02) What you Should Know About The CalWORKs 60-Month Time Limit

11-052
TEMP 2250 (4/11) State Law Changes MAP Levels For Cash Aid Recipients
TEMP 2252 (4/11) State Law Changes The CalWORKs Income Disregards

11-051
NA 200 (4/11) Notice Of Action - Multipurpose - Incl Budget

11-050
TEMP 2234 (4/09), TEMP 2160 (6/03) and TEMP 2160A (6/03)

11-049
TLR 9163A (3/11)  Request For Live Scan Service For TrustLine Registry Applicants

11-048
TLR 9163 (3/11)  Request For Live Scan Service For Subsidized TrustLine Registry Applicants

11-047
TLR 301E (3/11)  TrustLine Reference Requests

11-046
TLR 4 (3/11)  TrustLine Registry - "The California Registry Of In-Home And License-Exempt Child Care Providers" Ancillary Day Care Center

11-045
SOC 369A (3/11)  Kinship Guardianship Assistance Payment (KIN-GAP) Program Agreement Amendment

11-044
LIC 9194 (3/11)  Live Scan Instructions For State Licensed Facilities

11-043
LIC 9163B (3/11)  Request For Live Scan Service - Long Term Care Ombudsman - Applicant Submission

11-042
LIC 9163 (3/11)  Request For Live Scan Service - Community Care Licensing - Applicant Submission

11-041
LIC 508D (3/11)  Out-Of-State Disclosure & Criminal Record Statement - Foster Family Homes, Small Family Homes, Certified Family Homes

11-040
LIC 508B (3/11)  Criminal Record Statement - Long-Term Care Ombudsman Program

11-039
LIC 508A (3/11)  Criminal Record Statement - Adoption Facilitator

11-038
LIC 508 (3/11)  Criminal Record Statement

11-037
LIC 198B (3/11)  Out-Of-State Child Abuse/Neglect Report Request

11-036
LIC 198A (3/11)  Child Abuse Central Index Check For State Licensed Facilities

11-035 (not used)

11-034
AD 908A (1/11) Adoptions Information Act Statement

11-033
FC 8 (1/11) Federal Eligibility Certification For Adoption Assistance Program

11-032
SSP 14 (9/10) English and Spanish - Authorization For Reimbursement Of Interim Assistance Initial Claim Or Posteligibility Case

11-031
TEMP 2245 (1/11) Multilingual Important Information About Electronic Benefit Transfer (EBT)

11-030
DFA 377.7F (2/11) CalFresh Overissuance Notice For an Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IPV

11-029
DFA 377.7D3 (2/11) CalFresh Overissuance Notice for Administrative Errors Only

11-028
DFA 377.7D1 (2/11) CalFresh Overissuance Notice For Administrative Errors Only

11-027
DFA 377.7B (2/11) CalFresh Overissuance Notice For Inadvertent Household Errors Only

11-026
DFA 377.7D (2/11) CalFresh Overissuance Notice For Administrative Errors Only

11-025
SOC 369A (3/11)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment

11-024
SOC 818  (12/10) English & Spanish  - Relative Or Non-Relative Extended Family Member Caregiver Assessment

11-023
SOC 817  (12/10) Checklist Of Health and Safety Standards For Approval Of Family Caregiver Home

11-022
SOC 815  (12/10) Approval Of Family Care Giver Home

11-021
DFA 285B (2/11) CalFresh Budget Worksheet/Change Reporting Households

11-020
QR 285B (2/11) CalFresh Budget Worksheet/Quarterly Reporting Households

11-019
TLR 3 (2/11)  TrustLine To Community Care Licensing Criminal Background Clearance Transfer Request

11-018
TLR 2 (2/11)  TrustLine Registry - "The California Registry Of In-Home Child Care Providers"
- In-Home/License Exempt Child Care Provider Application

11-017 
TLR 1 (2/11)  TrustLine Registry - The California Registry Of In-Home Child Care Providers Subsidized Application

11-016
LIC 9092  (2/11)  Fire Pre-Inspection/Consultation Request

11-015
LIC 9020 (2/11)  Register Of Facility Clients/Residents

11-014
LIC 184B  (12/10)  Notification Of Incomplete Application (Family Child Care Home)

11-013
LIC 200 (2/11)  Application For A Community Care Facility Or Residential Care Facility For The Elderly License

11-012
KG 2 (1/11)  Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program

11-011
SOC 369A (12/10)  Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment

11-010
SOC 369 (12/10)  Agency-Relative Guardianship Disclosure

11-009
CW 51 (12/10) Child Support - Good Cause Claim For Noncooperation

11-008
SOC 426C (10/10) IHSS Program California Code Sections

11-007
SOC 426 (1/11)  IHSS Program Provider Enrollment Form

11-006
SOC 848, SOC 851, SOC 852, SOC 854, SOC 855, SOC 856 (1/11)
In-Home Supportive Services Program

11-005
SOC 847, SOC 852A, SOC 855A, SOC 855B, SOC 857, SOC 858A, SOC 858B, SOC 859A, SOC 859B, SOC 862, SOC 863 (1/11)
In-Home Supportive Services Program

11-004 (not used)

11-003
SAWS 2A QR (11/10) Rights and Responsibilities and Other Important Information

11-002
PUB 69 (9/10) County Forms Catalog 2010-11

11-001
LIC 9058 (1/11) Applicant/Licensee Rights