Example: La araa descendi lenta y silenciosamente. Date: _____ Full Medi-Cal benefits were granted pending verification of immigration status. CDSS CDs Ca Form. Any fields in the application or form with unrestricted text are intended for the requested information only. . c19-4 (Directing All Laboratories Conducting COVID-19 Diagnostic Tests to Report COVID-19 Test Information - Including Positive, Negative, and Inconclusive Test Results - To Local and State Public Health Authorities) issued on March 24, 2020 is rescinded in full in accordance with Section 9 of that Order. Join or sign in to find your next job. or 1.B.) Translated Spanish Forms Beginning With Letters A Through L Problems with downloading forms? Visit the CDSS CACFP web page or call 1-833-559-2420 for more information. Report changes as required. Cuando se ampla, se proporciona una lista de opciones de bsqueda para que los resultados . Create your signature and click Ok. Press Done. 1 Cdss Salaries in Berlin, Germany provided anonymously by employees. CCFRM604 (11/13) EN LG 4 Step 1: Tell us about the adult who will be our main contact for this application (continued) Are you applying for a child less than 1 year old? State of California - Health and Human Services Agency California Department of Social Services LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2 NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY 10.CHDP Program Trainings. Toma este curso. Privacy Notice on Collection When completed per MPP Section 21-115.2, including Armenian, Chinese and Spanish forms, the translations will be posted on our website. Expandir todo. FCCH - Pre-Orientation Registration Information: Wait! No inscrito. CDs ca form, create your personalized electronic signature in a couple quick steps, and streamline your workflow without leaving your browser. The prisoner's primary language is Spanish other (specify): b. I certify that I translated Order for Prisoner's Appearance at Hearing Affecting Parental Rights (JV-450) and this form for the prisoner in the prisoner's primary language to the best of my ability. Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 To view the minimum operating system requirements to take the online orientation, click the following link: Operation Requirements If you need assistance or have questions please click the Contact Support Link: Contact Support Directions 08/01/2011. Follow the step-by-step instructions below to design your monthly earnings form pa 167 pdf: Select the document you want to sign and click Upload. CDSS forms and publications are available only in Portable Document Format (PDF). Forms &. Safeguarding Information for the Financial Assistance Programs - 45 CFR section 205.50. Medi-Cal Mail-In application: Single Streamline Application Farsi Hmong Korean Laotian Arabic Armenian Cambodian Chinese Russian Spanish Tagalog Vietnamese SOC 2298 - In-Home Supportive Services (IHSS) Program and Waiver Personal Care Personal Services (WPCS) Live-In Self-Certification Form for Federal and State Wage Exclusion. 1.ACEs Aware Toolkit. $0 . Now semi-retired, he is spending his time on select startup and . Este botn muestra el tipo de bsqueda seleccionado. Copies of alien status documents are in the case file. Press Done after you complete the form. You will receive written notice of your eligibility no later than 30 days from the date of your signature on this form. Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Calendar Fiscal Year 2019-20 EESD-9730 (XLS) Tips for Using Adobe PDF Files Spanish forms beginning with the letters M through Z For Spanish forms beginning with the following letters click below: CDSS forms and publications are available only in Portable Document Format (PDF). Search By Facility Number Search By Facility Group Foster Family Agencies 24 Hour Residential Care for Children Adult Residential and Daycare Elderly Assisted Living Child Care Home Care Organization All Facility Types [Back] Note, this form must be submitted within 10 days of your reported food-loss or your household may not be eligible to receive replacement benefits. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. Personal information may include: name, social security number, physical description, home address, home telephone number, education or financial, medical or employment history, etc. Emergency Disaster Drill Log California Community Care Licensing (CCL) Requirements Licensed child care programs must conduct emergency drills at least once every 6 months. Resources for Parents and Families Resources for Parents and Families Information for parents and family members about early childhood education. California Department of Social Services Traduzione Context Correttore Sinonimi Coniugazione. Here's How - Use Starting June 1, 2020, CW 2166 (11/21) - Multilingual Work Really Pays! For more consumer information on security please see the California Department of Justices, Security Awareness Change in Service. If your office has internet access you may obtain this notice from the CDSS webpage at: Forms/Brochures. LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License. Effective immediately, Health Officer Order No. Access forms used by the Department of Health Care Services. You only need to mark provisions that pertain to your contract; if a provision does not apply then leave blank. Language Access Complaint Form. (Spanish) Franais (French) . Energy Assistance Application. Give the County proof of the information you have when it is needed. This course reviews monitoring requirements, staffing, completing monitoring reports, and conducting the five-day reconciliation. Jul 2021 - Present1 year 8 months. Services Denied . The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms (online or hardcopy) for our various programs. 01/28/2020. 1.A. Leccin 1 3 Temas | 1 Prueba . be ready to get more Create this form in 5 minutes or less Get Form Video instructions and help with filling out and completing Personal Rights LIC 613a Form Find a suitable template on the Internet. For more information, review the online CDSS Privacy Policy Statement. Forms for contractors of Early Learning and Care Division subsidized child care to give parents when family situations change. Combining years of human cybersecurity expertise and insights with ML-powered and Cloud-delivered products and services . The completed AD-3027 form or letter must be submitted to USDA . CDA Forms; Information Security; Program Memos; MSSP Newsletter. may include calling radiology providers for copies of mammogram reports) Child Abuse Central Index Forms Child Abuse and Neglect Reporting Forms The following forms are for use by government agencies and mandated reporters pertaining to child abuse cases. The spider descended slowly and silently. 2. Servicios Sociales de California (CDSS), y/o el Condado en donde yo reciba servicios. (916) 440-7370, 711 (California State Relay) Email: CivilRights@dhcs.ca.gov. They will direct you to your program representative. Search. Multipurpose Senior Services Program. The adverbs before take the feminine form of the adjective. Program Summary The Child and Adult Food Care Program (CACFP) is a state and federally funded Child Nutrition Program (CNP) designed to provide nutritious meals and snacks served to infants, children, and adults. 10/11/2022. Ph'D in Physics and quantitative Mathematics background. Public Records Act - Government Code section 6250 et seq. How to complete the Get And Sign California lic 702 2008-2019 Form online: To get started on the form, use the Fill camp; Sign Online button or tick the preview image of the form. Give it a little time before the Ihss Medical Certification Form is loaded 2074-EG. CF 285 (4/15) RIGHTS AND RESPONSIBILITIES You have a responsibility to: Give the County all information needed to determine your eligibility. Security Awareness, Copyright 2023 California Department of Social Services. 1. CPS Awareness Poster - Spanish (PDF) The CPS Awareness Poster is available electronically in 11 other languages. Collection of this information is required to deliver the specific services, but use of these services is voluntary. Please do not provide personal information that is not requested. 5. 6.CHDP Forms. FDU 113 (7/22) - Civil Rights Annual Training Checklist For CSFP And TEFAP, FS 31 ENG/SP (2/09) - Notice To All Food Stamp Recipients - Important-Please Read - Things You Need To Know, FSP 1 (8/14) - Family Stabilization Program Evaluation Request, FSP 2 (1/21) - Family Stabilization Program Denial Notice, FSP 3 (8/14)Family Stabilization Program Notice of Change in Program Status, GEN 1179 (5/18) - Complaint of Discrimination, GEN 1388 (9/15) - Language Accessibility Services Complaint Form, GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case, HCS 100 (11/21) - Application For Home Care Aide Registration or Renewal, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Providers Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (KinGAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (9/21) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (8/21) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/21) - Resource Family Approval Certificate, LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP), LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers -Pre-30-Day NOIA, LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 192 (7/03) - Notiification Of Initial Application Denial, LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (8/21) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200A (2/17) - Application For A Child Care Center License, LIC 215 (7/04) - Applicant Information - Facility License, LIC 279 (2/09) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 301E (6/22) - Reference Request - Exemption, LIC 308 (11/02) - Designation of Facility Responsibility, LIC 309 (6/01) - Administrative Organization, LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment Caregiver Background Check, LIC 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 421FC (7/17) - Civil Penalty Assessment Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment Immediate $500 And Repeat Violations, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 508 (7/21) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Ombudsman Program, LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/22) - Physician's Report For Community Care Facilities, LIC 603 (6/22) - Preplacement Appraisal Information, LIC 605A (7/22) - Release Of Client/Resident Medical Information, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (12/21) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residentail Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 613C (1/19) - Personal Rights Residential Care Facilities for The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication and Destruction Record, LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624-LE (4/17) - Law Enforcement Contact Report, LIC 625 (11/19) Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent for Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Exclusions And Reinstatement, LIC 995E (10/09) - Caregiver Background Check Process, LIC 995F (10/09) - Caregiver Background Check Information, LIC 999 (3/99) - Facility Sketch Floor Plan/Yard Plan, LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children In Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (7/22) - Telecommunications Device Notification, LIC 9163 (3/21) - Request Live Scan Service - Community Care, LIC 9166 (2/01) - Consent/Verification for Nebulizer Care, LIC 9182 (11/15) - Criminal Background Clearance Transfer Request, LIC 9188 (11/15) - Criminal Record Exemption Transfer Request, LIC 9211 (9/21) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9281 (01/22)- Small Family Home Risk Assessment. 10-XXTO:ALL COUNTY WELFARE DIRECTORSALL IHSS PROGRAM MANAGERSREASON FOR THISTRANSMITTAL[ ] State Law Change[ ] Federal Law or RegulationChange[ ] Court Order[ ] Clarification Requested byOne or More Counties[ ] Initiated by CDSSSUBJECT:QUESTIONS AND ANSWERS REGARDING THE EXPANDED IN-HOME SUPPORTIVE SERVICES (IHSS) PROVIDER . FORMS MANAGEMENT REPRESENTATIVES Utilize the Sign Tool to create and add your electronic signature to signNow the Get And Sign LIC 9182 (11/15) Criminal Background Clearance Transfer . LIC 281 (9/04) - Application Instructions for A Facility License. RECIBO DE LA NOTIFICACIN A LOS PADRES (Copia para el establecimiento) sobre los otros nios que reciben cuidado Yo, _____, doy acuse de recibo de la notificacin que es Box) City State Zip EBT card was reported lost/stolen to the county or . Child Care Services Forms Annual Summary of Eleven- and Twelve-Year-Old Children in Early Learning and Care Division (ELCD) Child Care Programs CD-9608Bx (XLS) Attendance and Fiscal Reporting forms are available through the Child Development Fiscal Services website. Quality assurance review of submitted forms for PSU; Troubleshooting for missing elements (i.e. 11.Medi-Cal News Flash. Use this step-by-step instruction to fill out the Get And Sign Preadmission health history spanish 2008-2019 Form swiftly and with idEval precision. 13.Home Testing Kits. New: CDSS has launched a Mobile App for this website now available on the App Store and Google Play. #OpenAI Microsoft ChatGPT Healthcare #digitalhealth #saude5ponto0 2824-EL. CHDP Provider Resources. Information Practices Act - Civil Code section 1798 et seq. Mailing Address (Number, Street, P.O. Any personal information collected is governed by the requirements of the following authorities and all other laws pertaining to personal information: CDSS collects personal information directly from individuals who volunteer to obtain some of our services. March XX, 2010ALL-COUNTY LETTER (ACL) NO. Your Email address. NA 1208 (2/00) - Basic Approval. Coniugazione Documents Dizionario Dizionario collaborativo Grammatica Expressio Reverso Corporate. The California Department of Social Services (CDSS) serves, aids and protects needy and vulnerable children and adults in ways that strengthen and preserve families, encourage personal . School or child care personnel then fill in date (month/day/year) of each immunization the student has received from the Immunization Record presented by Empezar. CDSS, Clinical Pathways, Evidence Based Medicine, Healthcare provider space and HIS, contributed for Online training material . Notice of Action (Complete Either 1.A. The information collected will not be shared with any other government agencies, unless required or allowed by law to administer programs. Start on editing, signing and sharing your Ihss Medical Certification Form online with the help of these easy steps: Click on the Get Form or Get Form Now button on the current page to make access to the PDF editor. Forms The following forms are references in this file: 02-11 02-11sp Adoption Telling Adoption Telling (Spanish) Subscribe. That's what a next generation of #cdss look like. Publications. Welfare and Institutions Code section 10850. Statewide Administrative Manual (SAM) section Privacy 5310 et seq. If appealed, appeal is due by: Date (Note: Appeal Instructions are on reverse side.) Application for Registration as a School Audiometrist - PM 101 Save prior to filling it out. If you do not see the form you need, please check if it can be ordered through the Children's Medical Services (CMS) Catalog or contact us and we will try to accommodate your request. Apply a check mark to indicate the choice where required. The languages include: Arabic, Chinese (simplified and traditional), Farsi, Hmong, Khmer, Korean, Punjabi, Russian, Tagalog, Vietnamese. #OpenAI Microsoft ChatGPT Healthcare #digitalhealth #saude5ponto0. 3) Forms Management Program related resources e.g., Electronic Signatures Toolkits. The County will give you information about what, when, and how to report. Join to apply for the ASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at California Department of Social ServicesASSOCIATE GOVERNMENTAL PROGRAM ANALYST role at Complete child's name and address information section, or ask parent or guardian to complete this section only. Here's How, CW 2184 (8/16) - CalWORKS 48-month Time Limit, CW 2184 (4/21) - CalWORKs 60-Month Time Limit, CW 2186A (12/12) - CalWORKs Exemption Request Form, CW 2186A (4/21) - CalWORKs Exemption Request Form, CW 2186B (4/21) - CalWORKs Exemption Determination, CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit, CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit, CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program, CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42nd Month On Aid, 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), CW2190A (4/16) - CalWORKs 48-Month Time Limit Extender Request Form, CW2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form, CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form, CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits, CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2205 (10/12) - New Rules For CalWORKs Welfare-To-Work Activities, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (12/20) - 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, 2021, 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), CW 2219 (5/16) Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child), CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs, CW 2224 (2/20) - CalWORKs Home Visiting Initiative (HVI), DFA 377.1A (3/02) - Notice Of Denial Or Pending Status, DFA 377.7A (4/21) - Notice Of Administrative Disqualification, DFA 377.7D2 (10/00) - Food Stamp Repayment Notice for Administrative Errors Only, Final Notice, DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only, DFA 377.7F (6/18) - CalFresh Overissuance Notice For An Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IVP, DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV)Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Discontinuance, DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 421 (7/99) - Notification Of Open Record And Waiver Of Time, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/Food Stamps, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (11/21) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A ENG/SP (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (6/22) - The Emergency Food Assistance Program (TEFAP) 2022Income Guidelines, EFA 15 (6/22) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2022 Income Guidelines, FC 2 (11/04) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC), FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC), FC 31 (8/16) Accreditation Reimbursement Request. Cloud-Delivered products and Services space and his, contributed for online training material then! Full Medi-Cal benefits were granted pending verification of immigration status Care Division subsidized Child Care to Parents. To: give the County all information needed to determine your eligibility no later than 30 days the! 440-7370, 711 ( California State Relay ) Email: CivilRights @ dhcs.ca.gov loaded 2074-EG status. Mark provisions that pertain to your contract ; if a provision does apply... If a provision does not apply then leave blank XX, 2010ALL-COUNTY letter ( ). Early Learning and Care Division subsidized Child Care to give Parents when situations. Proof of the adjective publications are available only in Portable Document Format ( PDF ) cps... Granted pending verification of immigration status ; if a provision does not apply then leave blank cdss forms spanish Financial Assistance -! Condado en donde yo reciba servicios collection of this information is required to the... 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