Mien
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A
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C
- CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers)
- 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
- CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read
- CF 10 (12/13) - Dependent Care Cost Affidavit
- CF 11 (9/22) - Notice To All CalFresh Recipients - Important - Please Read - Use Starting October 1, 2022
- CF 11 (8/23) - Notice To All CalFresh Recipients - Use Starting October 1, 2023
- CF 12 (6/23) - Notice to CalFresh Recipients
- CF 12 LP (6/23) - Notice to CalFresh Recipients - Large Print
- CF 18 ENG/MIEN (2/14) - Important Information
- CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits
- CF 21 (3/14) - Release Form
- CF 23 CR (2/14) - CalFresh Benefits How To Report Household Changes
- 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 34 (12/20) – CalFresh Notice of Change: Semi-Annual Reporting Eliminated
- CF 37 (11/16) - Recertification For CalFresh Benefits
- CF 285 (8/21) - Application For CalFresh Benefits
- CF 285LP (4/21) - Application For CalFresh Benefits - 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 377.1LP (5/20) - Notice Of Approval For CalFresh Benefits - Large Print
- CF 377.1A (8/21) - Notice Of Denial Or Pending Status
- CF 377.10 (2/24) - CalFresh Notice Of Denial/Disqualification For Failure To Meet General CalFresh Work Rules
- CF 377.11 (6/18) - 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 (6/18) - CalFresh Informational Notice - CalFresh Time Limit For Able-Bodied Adults without Dependents (ABAWDs)
- 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 377.6 (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
- 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 (10/17) - 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 (6/18) - CalFresh Overissuance Notice For Administrative Errors (AE) - Large Print
- CF 377.7E1 (1/14) - CalFresh Repayment Agreement For Administrative Errors Only
- CF 377.7F (10/17) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV)
- CF 377.7F LP (2/18) - CalFresh Overissuance Notice - Change From Inadvertent Household Error (IHE) To Intentional Program Violation (IPV) - Large Print
- CF 377.7F1 (10/17) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV)
- CF 377.7F1 LP (2/18) - CalFresh Repayment Final Notice - Intentional Program Violation (IPV) - Large Print
- CF 377.7G (3/18) - CalFresh Intentional Program Violation (IPV) Notice - Due To Trafficking
- CF 377.7H (2/23) - CalFresh Informational Notice - Potential Intentional Program Violation (IPV)
- CF 377.9 (8/20) - Notice Of Back CalFresh Benefits
- CF 377.9LP (8/20) - Notice Of Back CalFresh Benefits - Large Print
- CF 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 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) - Disqualification Consent Agreement CalFresh Program
- CF 485 (10/23) - CalFresh Elderly Simplified Application
- CF 485 LP (12/23) - CalFresh Elderly Simplified Application - Large Print
- CF 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 SSA 1 (9/20) - Information For Households Applying For CalFresh With The Social Security Administration
- CF SSA 1LP (9/20) - Information For Households Applying For CalFresh With The Social Security Administration (20pt Font
- CFAP 377.7B (8/23) – California Food Assistance Program (CFAP) - State CalFresh Overissuance Notice Inadvertent Household Error (IHE) - Use Starting October 1, 2025
- 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
- CTRI 01 (10/20) - California Tax Return Information (CTRI) Notification To Client
- 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 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 63 (11/20) - Request For Income And/Or Resource Verification
- CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs
- CW 377 (12/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV)
- 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 (4/21) - Your CalWORKs 60-Month Time Limit - Use Starting May 1, 2022
- CW 2189A (9/20) – Notice Of Your CalWORKs Time Limit – 54TH Month On Aid (Use Starting May 1, 2022)
- CW 2189B (9/20) – Notice Of Your CalWORKs Time Limit – 57TH Month On Aid (Use Starting May 1, 2022)
- CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form - Use Starting May 1, 2022
- CW 2190B (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 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 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
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E
G
M
- M16-505A (7/02) - Designated Alternate Cardholder
- M16-705 (6/23) - EBT Adjustment Denial
- M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
- M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption - Use Starting May 1, 2022
- M40-107A (4/21) - Time On Aid (no previous NOa issued), Other - Use Starting May 1, 2022
- M40-107B (4/21) - Time On Aid at Redetermination - Use Starting May 1, 2022
- M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022
- M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients - Use Starting May 1, 2022
- 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
- M40-107F2 (4/21) - Extender Ended - Use Starting May 1, 2022
- M40-107G (1/22) - 60th Month On Aid, Discontinue - Use Starting May 1, 2022
- M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue
- M40-107J (4/21) - Timed-Out Adult, Partial Approval - Use Starting May 1, 2022
- M40-107J1 (4/21) - Approval After 60 Months on Aid - Use Starting May 1, 2022
- M40-107K (4/21) - Increase Grant due to TOA Adjustment - Use Starting May 1, 2022
- M40-129B (11/09) - Full Payment - Approve
- M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve
- M40-129C (12/90) - Miscellaneous, 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
- M40-181 (9/13) - SAWS 2 Redetermination Of Eligibility
- 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
- M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval
- M44-207K (5/20) – Financial Eligibility, Discontinue
- M44-207K1 (5/20) - Minor Parent, Financial Eligibility
- M44-207M (8/20) - Financial Eligibility, Deny
- 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
- M44-315A (5/20) - $10 Minimum Payment, Change - Use Until April 30, 2022
- M44-315A (8/21) - $10 Minimum Payment, Change - Use Starting May 1, 2022
- 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 SAR (9/13) - No Change/Mid-Period Report of Property
- M44-316D SAR (9/13) - Notice Of Action - Change In Income
- M44-340 (2/23) - Underpayment Adjustment, Approval
- M44-350I SAR (9/13) - Notice Of Overpayment
- M44-350K (6/24) - EBT Replacement Denial
- M44-350L (12/18) - Notice Of 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
- M81-215E (4/21) - Time Limit Diversion - Use Starting May 1, 2022
- M81-215F (4/21) - Time Limit Diversion - Use Starting May 1, 2022
- M82-812B (6/24) - End of Cash Aid Following Family Reunification Discontinuance - Child Returned to Home
- M82-820A (9/21) - No Eligible Person, Deny
- M82-820D (9/23) - No Longer Eligible, Discontinue
- M82-832H (10/20) - Child Does Not Meet Requirements (SB 380)
N
- NA Back 9 (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412)
- NA Back 9 LP (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412) (Large print)
- 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 210 (7/19) - 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 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 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 530 (4/21) - Notice Of Action - 60-Month Time Limit - Use Starting May 1, 2022
- NA 531 (7/19) - Notice Of Action - Continuation Page - 48-Month Time Limit - Use Starting June 1, 2020
- 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 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 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 Services Denial
- NA 835 (3/20) - Notice of Action - Child Care Services Discontinuance
- 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 845 (3/14) - Notice Of Action - Sanction and Removal Of The Other Parent's Needs
- 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 995 (5/13) - Food Stamp Notice of Denial/Disqualification For The California Food Assistance Program
- 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 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 1273 (7/13) - Electronic Notification Agreement
- NA 1274 (7/13) - Electronic Notification Notice
- NA 1275 (7/13) - Electronic Notification Cancellation Notice
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W