2016 Notice Of Form Changes
16-149
AD 929A (12/16) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program
16-148
FC 01B (12/16) - Transitional Housing Program Plus Foster Care (THP + FC) Program & Other Revenue
16-147
FC 01A (12/16) - Transitional Housing Program Plus Foster Care (THP + FC) Program Cost Report
16-146
PUB 468 (10/16) - Approved Relative Caregivers Funding Option Program
16-145
ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved
16-144
SOC 826A (11/16) - Child Near Fatality - County Report Of Services Provided And Actions Taken
16-143
LIC 9214 (6/16) - Application For Administrator Certification - Administrator Certification Program
16-142
LIC 9141 (6/16) - Vendor Application/Renewal - Administrator Certification Program
16-141
LIC 9140 (11/16) - Request for Course Approval - Administrator Certification Program
16-140
LIC 9139 (11/16) - Renewal of Continuing Education Course Approval - Administrator Certification Program
16-139
AD 929 (11/16) - Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program
16-138
M44-316E (10/16) - Mid-Period Change Due To The Death Of A Child
16-137
CW 2.1Q (10/16) - Support Questionnaire
16-136
CF 37 (11/16) - Recertification For CalFresh Benefits
CF 285 (11/16) - Application For CalFresh And Benefits
16-135
NA 791 (11/16) - Notice Of Action - Approval/Denial/Change
16-134
RFA 01A (11/16) - Resource Family Application
RFA 05A (11/16) - Resource Family Approval Certificate
16-133
ARC 1A (11/16) - Rights, Responsibilities, And Other Important Information
16-132
ARC 1 (11/16) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program
16-131
NA 1281 (11/16) - Notice Of Action - Change Approved Relative Caregiver (ARC) Payment
16-130
NA 1280 (11/16) - Notice Of Action - Discontinue Approved Relative Caregiver (ARC) Payment
16-129
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
16-128
FC 31 (11/16) - Accreditation Reimbursement Request
16-127
NA 822 (7/16) - Notice Of Action - Transportation Change
16-126
NA BACK 9 (11/16) - ACA/Medi-Cal
16-125
RFA 01B (10/16) - Resource Family Criminal Record Statement
RFA 07 (10/16) - Resource Family Approval (RFA) Health Screening
16-124
TEMP 2262 (9/16) - In-Home Supportive Services Program Notice To Provider Of Provider Ineligibility Failure To Submit SOC 846 (REV. 11/15)
TEMP 2262A (9/16) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Failure To Submit SOC 846 (REV. 11/15)
16-123
CW 2190A (4/16) - CalWORKs 48-Month Time Limit Extender Request Form
CW 2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Form
16-122
CW 2184 (8/16) - CalWORKs 48-Month Time Limit
CW 2189 (3/15) - Notice of your CalWORKs Time Limit - 42nd Month on Aid
16-121
AD 900B (9/16) - Statement Of Understanding Independent Adoptions Program - Alleged Father of an Indian Child - Independent Adoptions Program
16-120
WTW 50 (6/16) - Program Integrity Request For Regulation Interpretation
16-119
SAR 2 CR (7/15) - Reporting Changes For Cash Aid And CalFresh - Obsolete
AR 2 CR (7/15) - Reporting Changes For CalWORKs And CalFresh - Obsolete
16-118
FC 1B (10/16) - Transitional Housing Pus Foster Care (THP+FC) Program & Other Revenue
16-117
FC 1A (10/16) - Transitional Housing Program Plus Foster Care (THP+FC) Program Cost Report
16-116
RFA 08 (9/16) - Resource Family Approval (RFA) Tuberculosis (TB) Screening Questionnaire
RFA 802 (9/16) - Complaint Intake Report
16-115
RFA 02 (7/16) - Resource Family Out-Of-State Child Abuse Registry Checklist
16-114
CF 37 (9/16) - Recertification For CalFresh Benefits
CF 285 (9/16) - Application For CalFresh And Benefits
16-113
CF 11 (8/16) - ENG/SP - Notice To All CalFresh Recipients Important - Please Read
16-112
SOC 2245 (10/16) - In-Home Supportive Services (IHSS) Fraud Data Reporting Form
16-111
PUB 13 (8/16) - Your Rights Pamphlet (Requires 8-1/2" x 14" paper printed landscape)
PUB 13 (8/16) - Your Rights Pamphlet (Large print 8-1/2" x 11")
16-110
TEMP 2260 (8/16) - Changes To The California Work Opportunity And Responsibility To Kids (CalWORKs) Maximum Family Grant (MFG) Rule
TM44-314 (8/16) - Basic Approval
16-109
CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old
CW 2218 (7/16) - 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)
16-108
SOC 873 (10/16) - In-Home Supportive Services (IHSS) Program Health Care Certification Form
SOC 874 (10/16) - In-Home Supportive Services (IHSS) Program Notice To Applicant Of Health Care Certification Requirement
16-107
TEMP 2250 (7/16) - State Law Changes Maximum Aid Payment (MAP) Levels For Cash Aid Recipients
TM44-315I (8/16) - Law Change to MAP levels
16-106
AD 900 (9/16) - Statement Of Understanding Independent Adoptions Program – Parent Who Gave Physical Custody (Custodial Parent) of the Indian Child to the Petitioner(s) - Independent Adoptions Program
16-105
AD 927 (9/16) - Statement Of Understanding - Independent Adoptions Program - Indian Child
16-104
AD 900A (9/16) - Statement of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (non-custodial) Of The Indian Child To The Petitioner(s) - Independent Adoptions Program
16-103
PUB 461(8/16) - Volunteer Emergency Service Team (VEST)
16-102
RFA 01C (8/16) - Resource Family Application-Confidential
16-101
FC 30 (8/16) - Group Home Extension Request
FC 31 (8/16) - Accreditation Reimbursement Request
16-100
PUB 400B (9/16) - Safely Surrendered Baby Kit--Order Form
16-099
SOC 851A (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Incomplete Provider Process 15-Day Notification
16-098
SOC 2293 (7/16) - 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)
16-097
SOC 2292 (7/16) - 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)
16-096
SOC 2291 (5/16) - For Posting Info Only
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)
16-095
SOC 2290 (5/16) - For Posting Info Only
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)
16-094
SOC 2289 (5/16) - For Posting Info Only
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
16-093
SOC 2288 (5/16) - For Posting Info Only
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
16-092
SOC 2287 (5/16) - For Posting Info Only
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
16-091
SOC 2286 (5/16) - For Posting Info Only
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
16-090
SOC 2285 (5/16) - For Posting Info Only
SOC 2285 (7/16) - In-Home Supportive Services Program Notice To Recipient Upholding Provider’s Fourth Violation (One-Year Period Of Ineligibility) For Exceeding Workweek And/Or Travel Time Limits
16-089
SOC 2284 (5/16) - For Posting Info Only
SOC 2284 (7/16) - In-Home Supportive Services Program Notice To Provider Upholding Fourth Violation (One-Year Period Of Ineligibility)For Exceeding Workweek And/or Travel Time Limits
16-088
SOC 2273 (8/16) - In-Home Supportive Services Program State Administrative Review Request Of Third Or Fourth Violation For Exceeding Workweek And/Or Travel Time Limits
16-087
SOC 2272 (5/16) - For Posting Info Only
SOC 2272 (6/16) - For Posting Info Only
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
16-086
SOC 2283 (5/16) - For Posting Info Only
SOC 2283 (6/16) - For Posting Info Only
SOC 2283 (7/16) - 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
16-085
SOC 862 (5/16) - In-Home Supportive Services (IHSS) Recipient Request For Provider Waiver
SOC 870 (5/16) - In-Home Supportive Services Program (IHSS) Notice To Provider Of Provider Eligibility Acknowledgment Of Receipt Of Waiver
16-084
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 857 (5/16) - IHSS Program Notice To Recipient Of Provider Eligibility Acknowledgement Of Receipt Of Waiver
16-083
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 855 (5/16) - In-Home Supportive Services Program Notice To Recipient Of Provider Ineligibility Incomplete Provider Process
16-082
SOC 813 (7/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Determination
16-081
FC 30 (7/16) - Group Home Extension Request
FC 31 (7/16) - Accreditation Reimbursement Request
16-080
PUB 400B (7/16) - Safely Surrendered Baby Kit-Order Form
16-079
SOC 2282 (5/16) - For Posting Info Only
SOC 2282 (6/16) - In-Home Supportive Services Program Notice To Provider Upholding Third Violation (90-Day Suspension Of Eligibility) For Exceeding Workweek And/Or Travel Time Limits
16-078
SOC 2280 (5/16) - For posting Info Only
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 (5/16) - For Posting Info Only
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
16-077
SOC 851 (5/16) - In-Home Supportive Services Program Notice To Applicant Provider Of Provider Ineligibility Incomplete Provider Process
16-076
SOC 813 (6/16) - Cash Assistance Program For Immigrants (CAPI) Indigence Exception Determination
16-075
SOC 826 (8/15) - Child Fatality/Near Fatality - County Statement of Findings and Information
16-074
SOC 859B (5/16) - IHSS Program Notice To Recipient Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction
16-073
SOC 857B (6/16) - In-Home Supportive Services Program Notice To Provider Of Provider Ineligibility Criminal Background Check Needed
SOC 858B (5/16) - IHSS Program Notice To Provider Of Provider Ineligibility Tier 2 Crimes Ineligibility - Subsequent Conviction
16-072
SOC 847 (5/16) - Important Information For Prospective Providers About The In-Home Supportive Services (IHSS) Program Provider Enrollment Process
SOC 848 (5/16) - 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
16-071
SOC 426 (5/16) - For posting info only - In-Home Supportive Services (IHSS) Program Provider Enrollment Form
SOC 426 (6/16) - In-Home Supportive Services (IHSS) Program Provider Enrollment Form
16-070
TLR 9163A (10/15) - Request For Live Scan Service TrustLine Registry Applicants
16-069
LIC 606 (4/16) - Residential Care Facility For The Elderly Disclosure Worksheet
16-068
CW 2218 (3/16) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-needy Caretaker Relative)
CW 2219 (5/16) - Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child)
16-067
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
16-066
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
16-065
WTW 18 (4/16) - Learning Needs Screening
16-064
LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home
16-063
PUB 341 (4/16) - Adoptions Services Bureau Career Opportunities
16-062
LIC 9150 (8/14) - Parent Notification - Additional Children in Care
16-061
SOC 396A (7/15) - Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment
16-060
LIC 624-LE (4/16) - Law Enforcement Contact Report
16-059
LIC 9214 (5/16) - Application For Administrator Initial Certification - Administrator Certification Program
16-058
LIC 9142A (5/16) - Roster Of Participants - For Vendor Use Only - ICTP Or CEU Courses - Administrator Certification Program
16-057
M40-125B SAR (4/16) - Restore After a SAR7 Discontinuance
M40-125C SAR (4/16) - Incomplete Semi-Annual Report (SAR7) Denial of Restoration
M44-207I SAR (4/16) - Financial Eligibility
16-056
LIC 9219A (3/16) - Crisis Day Care Sign-In
16-055
LIC 9219 (3/16) - Crisis Nursery Monthly Report
16-054
HCS 500 (4/16) - Registered Home Care Aide Training Log
16-053
LIC 421D (1/16) - Civil Penalty Assessment - Death
16-052
EFA 14 (4/16) - Emergency Food Assistance Program (EFAP) 2016 Income Guidelines
EFA 15 (4/16) - Alternate Pick-Up Request Form Emergency Food Assistance Program (EFAP) 2016 Income Guidelines
16-051
HCS 100 (12/15) - Application For Home Care Aide Registration
HCS 100 (10/15) - Revised - No GEN 127 posting for this previously approved version
HCS 100 (9/15) - New - No GEN 127 posting for this prior approved version
16-050
LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form
16-049
HCS 501 (9/15) - Personnel Record
16-048
HCS 001 (12/15) - Home Care Organization Suboffice Request
HCS 105 (12/15) - Home Care Aide Registry Request For Name/Address Change
16-047
DPA 435 (11/15) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification Hearing)
16-046
NA 1280 (2/16) - Notice Of Action - Discontinue Approved Relative Caregiver (ARC) Payment
16-045
NA 1279 (1/16) - Notice Of Action – Deny Approved Relative Caregiver (ARC) Payment
16-044
NA 1277 (1/16) - Notice Of Action - Approved Relative Caregiver (ARC) Overpayment
NA 1278 (1/16) - Notice Of Action - Approve Approved Relative Caregiver (ARC) Payment
16-043
AD 504 (5/15) - Relinquishment – Out of State In Armed Forces (Birth Mother/Biological Father/Presumed Father)
16-042
GEN 1389 (3/16) - Functional Assessment Service Team (FAST) Leader Course Application
16-041
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)
16-040
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 2267A (1/16) - In-Home Supportive Services Program Notice To Provider Denial Of Exception To Exceed Weekly Hours
16-039
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
16-038
CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs
16-034
LIC 9194 (3/11) - Live Scans Instructions For State Licensed Facilities (Obsolete)
16-033
LIC 9215 (3/04) - Application For Administrator Re-Certification (Obsolete)
16-032
TLR 9163 (12/15) - Request For Live Scan Service For Subsidized TrustLine Registry Applicants
16-031
TLR 4 (2/16) - TrustLine Registry "The California Registry Of In-Home and License-Exempt Child Care Providers" Ancillary Day Care Center
16-030
TLR 2 (12/15) - TrustLine Registry "The California Registry Of In-Home Child Care Providers"-In-Home/License exempt Child Care Provider Application
16-029
TLR 1 (12/15) - TrustLine Registry "The California Registry Of In-Home Child Care Providers"-Subsidized Application
16-028
LIC 9058 (12/15) - Applicant/Licensee Rights
16-027
LIC 809 (12/15) - Facility Evaluation Report
LIC 9099 (12/15) - Complaint Investigation Report
16-026
LIC 613C-2 (1/16) - Personal Rights In Privately Operated Residential Care Facilities For The Elderly
16-025
LIC 613B (1/16) - Personal Rights-Children's Residential Facilities
16-024
LIC 9163 (12/15) - Request Live Scan Service-Community Care Licensing
16-023
LIC 178 (12/15) - Deficiency/Penalty Review
16-022
LIC 421B (12/15) - Civil Penalty Assessment-Background Check/Child Care
LIC 421C (12/15) - Civil Penalty Assessment-Immediate $150
16-021
LIC 421D (12/15) - Civil Penalty Assessment-Death
LIC 421E (12/15) - Civil Penalty Assessment-Serious Bodily Injury/Physical Abuse
16-020
LIC 421 (12/15) - Civil Penalty Assessment
16-019
SOC 886 (12/15) - Social Worker Disclosure Report
16-018
LIC 9142A (1/16) - Roster Of Participants-For Vendor Use Only-ICTP Or CEU Courses-Administrator Certification Program
16-017
LIC 9141 (1/16) - Vendor Application/Renewal-Administrator Certification Program
16-016
LIC 9140A (1/16) - Request To Add Or Replace Instructor-Administrator Certification Program
LIC 9214 (1/16) - Application For Administrator Initial Certification-Administrator Certification
16-015
LIC 9140 (1/16) - Request For Course Approval-Administrator Certification Program
16-014
LIC 9139 (1/16) - Renewal Of Continuing education Course Approval-Administrator Certification
16-013
SR 10 (5/15) - Certification Of Audited Cost Data
16-012
SR 9 (5/15) - Federal Expenditure Certification
16-011
SR 8 (5/15) - Financial Audit Report Transmittal
16-010
TEMP 3007 (2/16) - In-Home Supportive Services (IHSS) Program Live-In Provider Overtime Exemption - Recipient Notice
TEMP 3008 (2/16) - In-Home Supportive Services (IHSS) Program Live-In Provider Overtime Exemption - Provider
16-009
SOC 2279 (1/16) - In-Home Supportive Services (IHSS) Program Live-In Family Care Provider Overtime Exemption
TEMP 3007 (1/16) - In-Home Supportive Services (IHSS) Program Live-In Provider Overtime Exemption - Recipient Notice
TEMP 3008 (1/16) - In-Home Supportive Services (IHSS) Program Live-In Provider Overtime Exemption - Provider
16-008
PUB 428 (1/16) - It's Your Money - Get It - The State and Federal Earned Income Tax Credit (EITCs)
PUB 429 (1/16) - California EITC is Here! Claim Your 2015 State And Federal Credits - You Earned It - It's Your Money
16-007
PUB 438 (11/15) - TrustLine Parent Pamphlet
PUB 439 (11/15) - License Exempt Provider Pamphlet
16-006
TEMP 3002 (11/15) - Important Information for the In-Home Supportive Services (IHSS) Recipient
TEMP 3006 (1/15) - Recipient/Provider Mailer Regarding Overtime Implementation Halt
16-005
SOC 2271 (11/15) - 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
TEMP 3000 (1/16) - In-Home Supportive Services (IHSS) Program Overtime And Workweek Requirements Recipient Declaration
TEMP 3001 (11/15) - Important Information for the In-Home Supportive Services (IHSS) Provider
16-004
SOC 426A (1/16) - In-Home Supportive Services (IHSS) Program Recipient Designation Of Provider
SOC 846 (11/15) - In-Home Supportive Services (IHSS) Program Provider Enrollment Agreement
SOC 2255 (11/15) - 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
16-003 (not used)
16-002
TLR 4 (12/15) - TrustLine Registry "The California Registry Of In-Home and License-Exempt Child Care Providers" Ancillary Day Care Center
16-001 (not used)