Duplicate Wage and Tax Statement (IRS Form W-2) Authorization. Stimulating Factor (M-CSF), Mouse, recombinat Impurities and/or Additives c* The remaining points may come from any list I II or III. El Departamento de Servicios Sociales (DSS) del Condado de Fresno desea informarle sobre que la cobertura continua de Med-Cal va a terminar y a partir del 1 de abril comenzara el proceso de las redeterminaciones anuales para renovar los beneficios de Med-Cal. SAR 7 Eligibility Status Report for Cash Aid and . If your contact information or household circumstances have changed, please update your information today by contacting DSS in one of the following ways: Online: www.MyBenefitscalwin.org or https://DSSPASS.fresnocountyca.gov, Mail: Fresno County Department of Social Services PO BOX 1912 Fresno CA 93718, Phone: 1-855-832-8082 Between 7:30 AM 4:30 PM. Leave Status. (Reference: CA Government Code Section 911.2), Presentation of a false claim is a felony. endstream endobj 44 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream If in office, Submit verification for Homeless Assistancevia the drop box using the providedHomeless Assistanceenvelopes located in the lobby. All Programs. Assessor Jobs. Share & Bookmark, Press Enter to show all options, press Tab go to next option, Partner : Fresno County Office of Education, Auditor-Controller / Treasurer-Tax Collector, Fresno County Employees' Retirement Association, Frequently Asked Death Certificate Questions, Frequently Asked Birth Certificate Questions, Genetically Handicapped Persons Program (GHPP), Communicable Disease Investigation Program, HIV - AIDS Reporting Requirements and Forms, Testing Services - Frequently Asked Questions, Traveling Abroad Immunizations Offered by FCDPH Immunization Program, Day Care, Preschool, and Grade School Immunizations, The Childhood Lead Poisoning Prevention Program (CLPPP), Medical Marijuana Identification Card Program, Madera County Emergency Medical Care Committee (EMCC), Tulare County Emergency Medical Care Committee (EMCC), Central California EMS Policies and Procedures, Public Health Emergency Preparedness (PHEP), Biological Agent and Diseases (Bioterrorism), Food Safety During Temporary Power Outages, California Environmental Reporting System (CERS), California Accidental Release Prevention Program (CalARP), Onsite Treatment of Hazardous Waste - Tiered Permit Program, Solid Waste Local Enforcement Agency (LEA), Epidemiology, Surveillance, and Data Management, Epidemiology - Frequently Asked Questions, Cumulative Reported Communicable Diseases Cases, Kindergarten Oral Health Assessment - Resources For Schools, Lifetime of Wellness: Communities in Action (LWCA), State Physical Activity and Nutrition Program, Partnerships to Improve Community Health (PICH), FCHIP - Fresno County Health Improvement Partnership, About Fresno County Office of Emergency Services, Child Health and Disability Prevention (CHDP) Program, Comprehensive Perinatal Services Program (CPSP), Health Care Program for Children in Foster Care (HCPCFC), Maternal Child Adolescent Health Useful Resources. It looks like your browser does not have JavaScript enabled. Departments Public Health Community Health Medical Marijuana Identification Card Program, Medical Marijuana Identification Card Program - Forms, Our Location: 1221 Fulton Street, First Floor Sacramento, CA 95899-7377, For General Public Information: The links below will take you to the State of California Dept. The CDSS webpage will be updated once an implementation date for the CFAP expansion has been confirmed. It is important that DSS has current contact information to ensure you receive all pertinent information in how to maintain your benefits. P O Box 11867, Fresno CA 93775-1867 Business Personal Property / e-File. Board and Care Statement CSF 168 - Medi-Cal/Health Coverage Application Reminder Letter CSF 165 - NOA (MC) (NA Back 9) . Si su informacin de contacto o las circunstancias del hogar han cambiado, reporte el cambio hoy comunicndose con el DSS de una de las siguientes maneras. Roughly 1% of the. Esperamos que este aviso anticipado le ayude a prepararse y presupuestar para minimizar cualquier dificultad para su hogar. If you have questions regarding the completion and submission of the forms, please contact the Placer County Recorder's Office at 530-886-5600, Monday through Friday, between 8 a.m. and 5 p.m. Adobe Acrobat Reader To view or print the forms in PDF file format, you will need an Acrobat PDF Reader. {o6M?fy]q. Phone: (559) 600-3434 Fax: (559) 600-7601 Then use WordPerfect to open the Word file. Claim for Damages Form Clerk of the Board of Supervisors 2281 Tulare Street, Room 301 Fresno. Proposition 19. . Votes. Important! Acrobat Reader Windows Media Player Word Viewer Excel Viewer PowerPoint Viewer Here you'll find the most commonly used forms for Child Support. Send csf via email, link, or fax. Child Support Forms - County of San Diego. You may find that you need an affidavit as a witness to an event or to verify the existence of certain facts, such as the rightful owner of a property, the . Rental Property is located in the City of Fresno; Tenant must meet income requirements and be below 80% Fresno County Median Area Income (AMI) Your renter's household is income-eligible. A claim form is available below or may be picked up at the Office of the Clerk of the Board of Supervisors. Please fill out the entire application form. Begininning in mid-Feburary, the California Department of Health Care Services (DHCS) will be issuing letters with information on the necessary steps to maintain your Medi-Cal coverage after the continuous coverage requirement ends. The COVID-19 Equity Project (CEP) expands UCSF Fresno's Mobile HeaL program by bringing equal access to barrier-free COVID and other health care services to target communities, in partnership with community-based organizations. Self-Employment Sworn Statement (CSF 35) . Review Your Value. Sign it in a few clicks Draw your signature, type it, upload its image, or use your mobile device as a signature pad. Please use the following links to access an application with Sworn Statement for an authorized copy of a birth, death, or marriage certificate. Please see the flyers below for more information onhow to protect your benefits from scams. Phone: 530-889-4300. assessor@placer.ca.gov. There has been a reported increase in EBT Scams. CDSS decided to obsolete this form and using sworn statements in lieu of this form until a self-employment form is created. 93721 More Announcements . An affidavit is a written statement, sworn to be true, that can be used as evidence in legal proceedings. WORKSHEE 17 Station St., Ste 3 Brookline, MA 02445. There are three variants; a typed, drawn or uploaded signature. SELF EMPLOYMENT FORMS CSF. instead of the Fresno 2229. Decide on what kind of signature to create. The latest versions of WordPerfect can also open Word documents and even save documents in Word format. Share & Bookmark, Press Enter to show all options, press Tab go to next option, Partner : Fresno County Office of Education, Auditor-Controller / Treasurer-Tax Collector, Fresno County Employees' Retirement Association, Statements of Economic Interests Form 700. To download a Word document from this page for use with WordPerfect, right click on it with your mouse and then select "Save Target As" from the pop up menu and save the file to your local drive. With this change, all Californians age 55 years or older, regardless of their immigration status, will be able to receive a monthly food benefit to help meet their basic needs. A sworn statement can be required by a project owner, financial institution, or a . 03. Here's what you need to know about using a California general affidavit form. f @[3dx endstream endobj 290 0 obj <>stream Reset Affidavits can be used in a variety of legal contexts . The Sheriff's Office patrols more than 6,000 square miles of Central California with a diversity of terrain that varies from open farmlands to . Type text, add images, blackout confidential details, add comments, highlights and more. The last emergency allotment will be issued in March 2023. Council Member Luis Chavez said. It includes information about who is owed money, how much they are owed, and the remaining balance on their contract. Nerve conduction studies revealed low Learn more Forms - DSS PASS - Fresno County Your Sworn Statement must be notarized. wg. Donor Authorization Form. 51. endstream endobj 289 0 obj <>stream Forms. 1-833-4CA4ALL Attestation Statement: Did you receive a summons and complaint in the mail? If you are requesting an authorized copy of a birth, death, or marriage certificate, you MUST complete the Sworn Statement included with the application and sign the statement (declaring under penalty of perjury that you are entitled by law to receive an authorized copy). to Default, Registered Environmental Health Specialist, California Health Facilities Information Database, Chronic Disease Surveillance and Research, Medical Marijuana Identification Card Program, Office of State Public Health Laboratory Director, Centers for Disease Control and Prevention. DocHub v5.1.1 Released! {JDJ3ZI?p8>=5522:vz/!+9JH/xfF-"%\CxVn9F+_6,iol- + "&]jwic]k x[@"&:6W Claims against the County of Fresno must be filed with the Clerk of the Board of Supervisors. 01. =? Espaol, - No CSF points are given for physical education courses taken in lieu of physical education subjects repeated to improve a grade courses involving clerking and office/teaching assisting and courses taken on a pass/fail basis. REFERENCES All County Letter 18-70 Eligibility and Assistance Standards Manual: 42 -701, 42 711.552, 42-711.646, 42-721.2, and 42-750 . CSF 22 - Employment Questionaire. )}B55NmQ%%0aY 8Cw UzFs~F~KG`~Oyqxln@0bFw%S-p$N\Mv(L:a cyV&%;|M~vw{bumJFNl&T4*jMaNN R[zYmoc&;7#05raY (L$dP5G|d[/8%9{3yCV^UlX?6nieGfb]i+$e~ Tips for Using Adobe PDF Files, Copyright 2023 California Department of Social Services, AAP 1 (11/22) - Request For Adoption Assistance Program Benefit, AAP 2 (11/22) - Payment Instructions Adoption Assistance Program, AAP 3 (6/22) - Reassessment Information - Adoption Assistance Program, AAP 4 (4/22) - Eligibility Certification Adoption Assistance Program, AAP 5 (9/18) - Adoptions Assistance Program Independent Adoptions Program, AAP 6 (11/22) - Adoption Assistance Program Negotiated Benefit Amount and Approval, AAP 7 (12/17) - Adoptions Assistance Program Statement Of Acknowledgement, AAP 8 (9/18) - Adoption Assistance Program Nonrecurring Adoption Expenses Agreement, AAP 9 (6/21) -Adoption Assistance Program (AAP) Level Of Care Rate Determination Matrix (AAP LOCMatrix) Instruction Guide, AAP 9A (5/21) -Adoption Assistance Program (AAP)Level Of Care Rate Determination Protocol Matrix, AAP 10 (10/21) -Prospective Or Adoptive Parent(s) Level Of Care (LOC) Reporting Tool, ABCD 239.7A (8/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program, ABCD 478A (5/20) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program, ABCDM 228 (ENG/SP) (6/99) - Applicant's Authorization For Release Of Information, ABCDM 229 (1/23) -Applicant/Recipients Authorization For Release Of Information To Community-Based Organization (CBO) In BenefitsCal, AD 1A (4/22) - Parental Consent To Adoption(In Or Out-Of-California), AD 1F (4/15) - Parental Consent To Adoption Outside California In Armed Forces - Independent Adoption Program, AD 2 (6/02) - Stepparent Adoption (Consent To Adoption By Parent Retaining Custody, AD 2A/2B (5/11) - Stepparent Adoption (Consent to Adoption by a Parent in or outside of California Giving Custody to Husband or Wife or Domestic Partner of Other Parent), AD 2D (3/08) - Stepparent Adoption Consent To Adoption By Parent Outside California In Armed Forces Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent, AD 8 (10/01) - Marriage/Divorce Verification (Combined With AD 19) - Agency And Independent Adoptions Program, AD 9 (11/07) - Independent Adoption Questionnaire - Independent Adoptions Program, AD 20 (4/15) - Refusal To Give Parental Consent To Adoption - Independent Adoptions Program, AD 20B (5/15) - Refusal To Give Consent To Adoption - Alleged Father - Independent Adoption Program, AD 22 (7/02) - Health Facility Minor Release Report - Agency And Independent Adoptions Program, AD 28 (8/03) - Notification Of Subsequent Action, AD 40 1 (8/03) - Adoptions wooksheet (Print 8 1/2 x 14), AD 42 I (3/02) - Independent Adoptions Program (Individual Case Report), AD 56D (1/02) - Independent Adoption Program & Adoption Set Asides - Independent Adoptions Program, AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care, AD 67 (5/15) - Information About The Birth Mother - Agency And Independent Adoptions Program, AD 67A (7/15) - Information About The Birth Father - Agency And Independent Adoptions Program, AD 70 (11/15) - Adoption Facilitator Registry Application, AD 71 (11/15) - Adoption Facilitator Registry - Trainee Application, AD 72 (4/22) - Adoption Facilitator Complaint Form, AD 90 (6/13) - Supporting Information For Issuance Of California Department Of Social Services Acknowledgement And Confirmation Of Receipt Of Child Freeing Documents, AD 100 (9/22) - Authorization For Use And/Or Disclosure Of Health Information Independent Adoption Program, AD 100A (7/20) - Authorization For Release, Use And/Or Disclosure Of Health Information, AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In Or Out-Of-California) - Independent Adoptions Program, AD 196 (2/02) - Request For Release Of Information, AD 200 (1/02) - Request For Case Record/Documents, AD 202B (1/13) - Intercountry Adoption Program Quarterly Statistical Report, AD 501 (6/14) - Relinquishment In or Out-of-County (Birth Mother/Biological Father/Presumed Father In California), AD 501A (9/14) - Relinquishment Out-of-State (Birth Mother/Biological Father/Presumed Father) (ENG/SP), AD 504 (5/15) - Relinquishment Out of State In Armed Forces (Birth Mother/Biological Father/Presumed Father), AD 508 (7/13) - Rescission Request/Rescission Of Relinquishment, AD 512 (1/14) - Psychosocial And Medical History Of Child, AD 512 NMD (8/13) - Psychosocial And Medical History Of Non-Minor Dependent, AD 513 NMD (10/13) - Non-Minor Dependent Adoption Mutual Disclosure Agreement, AD 521 (8/11) - Application For Adoption Of A Child, AD 524 (Bilingual) (3/99) - Physician's Examination Of Adoption Applicant/Petitioner, AD 551A (11/13) - Notification Of Procedure In Lieu Of Signing Relinquishment, Waiver or Denial, AD 558 (7/10) - Notice Of Placement (To Be Sent Within 15 Days of Placement), AD 580 (7/10) - Notice of Removal Of Child From Adoptive Home, AD 583 ENG/SP (5/15) - Relinquishment In Or Out Of County - Presumed Father Denies He Is The Birth Father in California, AD 584 (8/12) - Relinquishment Out of State - Presumed Father Denies He is the Birth Father, AD 586 (7/14) - Relinquishment In or Out-of-County (Alleged Natural Father In California), AD 588 (4/15) - Denial Of Paternity By Alleged Father - In Or Out Of California - Agency And Independent Adoptions Program, AD 590 (4/15) - Waiver Of Right To Further Notice Of Adoption Planning (Alleged Father In Or Out Of California) - Agency And Independent Adoptions Program, AD 590A (6/15) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Father In Or Out Of California - Agency And Independent Adoptions Program, AD 591 (12/14) - Relinquishment - Out-of-State (Alleged Natural Father), AD 593 (5/22) - Relinquishment Out of State in Armed Forces (Alleged Natural Parent), AD 594 (3/15) - Alleged Father's Consent To Adoption (In Or Out Of California) - Independent Adoptions Program, AD 824 (7/10) - Adoption Petition - Consent and Joinder, AD 830 (6/99) - Summary Claim For Reimbursement Private Adoption Agency Reimbursement Program (Welfare Institutions Code Section 16122), AD 836 (5/99) - Report Of Physician Attending Birth Of Child Placed For Adoption, AD 842 (3/17) - Alleged Father's Consent To Adoption (Outside California In The Armed Forces), AD 856 (5/21) - Notice To Discontinue Foster Care (FC) Payment, AD 859 (8/15) - Parental Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program, AD 860 (8/15) - Presumed Father's Consent To Adoption Of Indian Child (In Or Out-Of-California) - Independent Adoptions Program, AD 861 (8/15) - Consent To Adoption Of Indian Child By Alleged Father (In Or Out Of California) - Independent Adoption Program, AD 862 (3/12) - Relinquishment Of An Indian Child Out-Of-State (Alleged Natural Father), AD 863 (9/12) - Relinquishment Of An Indian Child Out of State - Birth Mother/Presumed Father, AD 864 (9/14) - Relinquishment Of An Indian Child In Or Out-Of-County - Birth Mother/Presumed Father In California, AD 866 (10/14) - Relinquishment Of An Indian Child In Or Out-of-County - Presumed Father Denies He Is The Birth Father In California, AD 867 (3/08) - Relinquishment of an Indian Child - Out-of-State - Presumed Father Denies He is the Birth Father, AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California, AD 880 (2/21) Declaration Of Birth Parent - Agency And Independent Adoptions Program, AD 885 (3/14) - Mother Or A Biological/Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian, AD 885A (4/22) -Statement Of Understanding Agency AdoptionProgram- Parent Or APresumed Parent Of AChild Who Is Detained, AJuvenile Court Dependent In Out-Of-Home Care, Or The Ward Of ALegal Guardian, AD 885C (2/15) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian, AD 885D (11/21) -Statement of Understanding - Alleged Parent of a Child Who is Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal Guardian, AD 887 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The Child To The Petitioner(s), AD 887A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s), AD 887B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father, AD 898 (1/11) - Consent Of CDSS Or Delegated County Adoption Agency - Independent Adoptions Program, AD 899 (3/08) - Statement of Understanding - Mother or a Presumed Father of the Indian Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or a Ward of a Legal Guardian, AD 899A (11/21) - Statement of Understanding - Mother or a Presumed Father of an Indian Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 899C (3/06) - Statement Of Understanding - Alleged Natural Father of the Indian Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 899D (11/21) - Statement Of Understanding -Alleged Parent of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian, AD 900 (8/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Gave Physical Custody (Custodial Parent) Of The INDIAN Child To The Petitioner(s), AD 900A (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The INDIAN Child To The Petitioner(s), AD 900B (3/18) - Statement Of Understanding Independent Adoptions Program - Alleged Father Of An INDIAN Child, AD 902 (2/22) - Consent For Arranging Contact, AD 904A (8/20) - Waiver Of Rights To Confidentiality For Siblings, AD 904B (9/20) - Waiver Of Rights To Confidentiality For Siblings Under The Age Of 18, AD 907 (7/10) - Adoptive Placement Agreement, AD 908 (5/22) - Adoptions Information Act Statement, AD 908A (1/11) - Adoptions Information Act Statement, AD 909 (12/99) - Photo Listing Data Sheet, AD 918 (11/03) - Family Assessment Questionnaire II, AD 924 (6/22) - Independent Adoption Placement Agreement - Independent Adoptions Program, AD 925 (8/15) - Independent Adoption Placement Agreement - Indian Child - Independent Adoptions Program, AD 926 (1/18) - Statement Of Understanding Independent Adoptions Program Parent Who Places The Child With The Prospective Adoptive Parent(s), AD 927 (3/18) - Statement Of Understanding Independent Adoptions Program - Parent Who Places The Indian Child With The Prospective Adoptive Parent(s), AD 928 (7/02) - Revocation Of Consent Independent Adoption Program - Independent Adoptions Program, AD 929 (9/18) - Waiver Of Right To Revoke Consent Independent Adoption Program - Independent Adoptions Program, AD 929A (4/21) - Waiver Of Right To Revoke Relinquishment Agency Adoption Program, AD 930 (7/11) - Independent Adoption Placement Agreement Transmittal - Independent Adoptions Program, AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment, AD 932 (2/21) - Notice of Entry for Intercountry Adoptions, AD 933 (12/20) - Intercountry Readoption Acknowledgment, AD 934 (1/21) Court Filing Cover Sheet For Intercountry Readoptions, AD 4040 (7/20) - Private Adoption Agency Reimbursement Program (PAARP) (Posted July 1, 2020), AD 4310 (8/07) - Adoption Programs Notice Required By Information Practices Act, AD 4313 (8/03) - Letter Requesting Parent Be Interviewed - Independent Adoptions Program, AD 4317 (3/20) - Revocation Of Relinquishment, AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement, AD 4324 (2/21) - Adoption Questionnaire I, AD 4328 (3/06) - Authorization For Release Of Personal Items, AD 4336 (4/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (Outside California In Armed Forces) - Independent Adoption Program, AD 4337 (10/21) - Criminal Record Statement, AD 4339 (12/14) - Relinquishment Out of State (Birth Mother/Biological Father/Presumed Father), AD 4348 (3/13) - Private Adoption Agency Reimbursement Program (PAARP), AD 4349A (12/14) - The Private Adoption Agency Reimbursement Program (PAARP) Full Time Equivalent, AD 4349B (12/14) - The Private Adoption Agency Reimbursement Program (PAARP) Full Time Equivalent, AD 4349C (12/14) - The Private Adoption Agency Reimbursement Program (PAARP) Full Time Equivalent, AD 4349D (12/14) - The Private Adoption Agency Reimbursement Program (PAARP) Full Time Equivalent, AD 4349E (12/14) - The Private Adoption Agency Reimbursement Program (PAARP) Full Time Equivalent, ADM 36 (6/99) - Medical Report Regarding Child To Be Adopted, ADSA 1 (3/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits, ADSA 1A (5/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits, ADSA 1AL (11/21) - Assistance Dog Special Allowance (ADSA) Application For Renewal Of Benefits, ADSA 1B (6/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits, ADSA 1L (5/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits, ADSA 1BL (7/21) - Assistance Dog Special Allowance (ADSA) Program Application For Benefits For Recipients Of Social Security Disability Insurance (SSDI) Benefits, ADSA 2 (10/21) Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program, ADSA 2L (12/21) Your Hearing Rights Under The Assistance Dog Special Allowance (ADSA) Program, ADSA 3 (10/21) - Assistance Dog Special Allowance (ADSA) Enclosure, ADSA 3L (11/21) - Assistance Dog Special Allowance (ADSA) Enclosure, AR 2 (11/13) - Reporting Changes For CalWORKs And CalFresh, AR 2 SAR (3/15) - Reporting Changes For CalWORKs And CalFresh, AR 3 (2/15) - Mid-Year Status Report For CalWORKs and CalFresh, ARC 1 (4/22) - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (ARC) Funding Option Program, ARC 1A (6/21) - Rights, Responsibilities And Other Important Information For the Approved Relative Caregiver Funding Option Program (ARC), ARC 2 (11/16) - Redetermination: Statement Of Facts Supporting Eligibility For The Approved, AUD 1400 (5/22) - Audited Attendance And Fiscal Report For Special Programs For The Severely Handicapped, AUD 2507 (5/22) - Audited Fiscal Report For Resource And Referral Programs, AUD 9500 (7/22) - Audited Attendance And Fiscal Report For Child Development Programs, AUD 9500A (5/22) - Audited Fiscal Report For Migrant Special Contracts, AUD 9500AP (8/22) - Audited Fiscal Report For CALWORKs, Alternative Payment Or Family Child Care Home Programs, AUD 9500MHCS (7/22) - Audited Attendance And Fiscal Report For Child Development Programs With Early Childhood Mental Health Consultation Services, AUD 9500S (7/22) - Audited Days Of Enrollment For Child Development Programs Three Years And Older One-Half-Time Direct Service Counties, AUD 9529 (5/22) - Audited Fiscal Report For Child Development Support Contracts, AUD 9530A (5/22) - Audited Reserve Account Activity Report, CAC 1 (3/22) - Request For One-Time Exception Corrective Action Plan, CAC 3(3/22) -Uncashed Child And Adult Care Food Program Reimbursement Remittance, CCD 9 (7/21) - Equipment Purchase Approval Request, CCD 11 (6/22) -Local Planning Council (LPC) County Priorities Report Form, CCD 17 (7/22) - California County Local Child Care Planning Council Needs Assessment - Template, CCD 19A (3/22) -Summary Request for Voluntary Temporary Interagency Transfer of Funds (Attachment A), CCD 19B (5/22) - Request to Release a Voluntary Temporary Transfer of the California Department of Social Services Contract Funds (Attachment B), CCD 19C (5/22) - Request to Release a Voluntary Temporary Transfer of the California Department of Social Services Contract Funds (Attachment C), CCD 20 (4/22) - Out-of-State Travel Approval Request Form, CCD 21 (8/22) - Parent Plan For Seeking Employment (PPSE), CCD 23 (9/21) - Fiscal Year 202122 Program Calendar, CCD 23 (12/21) - Fiscal Year 202223 Program Calendar, CCD 24 (2/22) - CCDD Emergency Closure Requests For Fiscal Year 2021-22, CCD 24 (8/22) - CCDD Emergency Closure Requests For Fiscal Year 2022-23, CCD 25 (9/22) Child Care And Development Monitoring Tool, CCD 26 (1/22) Confidential Application for Child Development Services and Certification of Eligibility, CCD 26A (1/22) Instructions for Completing Form CCD 26: Confidential Application for Child Development Services and Certification of Eligibility, CCD 27 (8/22) - Statement Of Parental Incapacitation, CCD 28 (1/22) Program Narrative Change Fiscal Year 2022-23, CCD 28 (9/21) -Program Narrative Change - Fiscal Year 2021-22, CCD 29 11/22) - CD-ICW Income Calculation Work Sheet Cash, Wages, Or Salary, CCD 30(11/21) - Continued Funding Application Fiscal Year 2022-23, CCD 30B (10/22) - Subcontract Certification, CCD32 (10/22) - Program Staffing Plan (FY 202223 CCTR Expansion RFA), CCD 33 (11/21) - Continued Funding Application Program Calendar For Fiscal Year 2022-23, CCD 33 (10/22) - Fiscal Year 2023-24 Program Calendar, CCD 34 (10/22) - Fiscal Year 202223 General Child Care And Development Program Expansion Funds Request For Applications, CCD 35 (8/22) - Educational Programs or Vocational Training Verification for Parent or Caretaker Attending Educational Programs or Receiving Vocational Training, CCD 38 (3/22) - Site Supervisor or Program Director Staffing Qualifications Waiver Request, CCD 39 (3/22) - Site Supervisor or Program Director Staffing Qualifications Waiver Extension Request, CCD 43 (9/22) - Certification Statement Regarding Composition Of LPC Membership, CCP 1 (3/15) - Declaration Of Exemption From TrustLine Registration And Health And Safety Self-Certification, CCP 4 (8/21) - Health And Safety Self-Certification (For license-exempt providers), CCP 6 (8/99) - Health And Safety Facility Checklist, CCP 7 (10/19) - CalWORKs Child Care Request Form And Child Care Payment Rules, CCP 8 (10/19) - CalWORKs Stage One Child Care Authorization Form, CCP 9 (8/17) - Child Care Program (CCP) 9 Request For Policy Interpretation, CCP 2145 (6/21) - CalWORKs Child Care Reimbursement Report, CF 1 (10/14) - Notice To All CalFresh Recipients - Important Please Read, CF 10 (12/13) - Dependent Care Cost Affidavit, CF 11 (9/21) - Notice To All CalFresh Recipients, CF 11 (9/22) - Notice To All CalFresh Recipients, CF 18 ENG/SP (2/14) - Important Information, CF 20 (2/14) - You Do Not Owe Anything For Receiving CalFresh Benefits, CF 24 (6/17) - CalFresh Program Request For Policy/Regulation Interpretation, 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 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 31 (6/19) - CalFresh Supplemental Form For Excess Medical Deductions, CF 31LP (6/19) - CalFresh Supplemental Form For Excess Medical Deductions, CF 32 (6/13) - CalFresh Request For Contact, CF 33 (6/19) - CalFresh Budget Worksheet - Special Medical/Shelter Deductions, CF 34 (12/20) CalFresh Notice of Change: Semi-Annual Reporting Eliminated, CF 37 (11/16) - Recertification For CalFresh Benefits, CF 100 (11/20) - CalFresh Request For Authorized Representative Drug Or Alcohol Treatment Center Resident, CF 101 (11/20) - CalFresh Request For Authorized Representative, CF 215 (6/19) - CalFresh Notification Of Inter-County Transfer, CF 285 (4/21) - Application For CalFresh Benefits, CF 285 LP (4/21) - Application For CalFresh Benefits, CF 285A (11/21) - Application For CalFresh Benefits, CF 286 SAR (12/15) - CalFresh Budget Worksheet/Semi-Annual Reporting Households, CF 303 (8/19) Replacement Or Disaster Supplement Affidavit, CF 304A (9/20) - Important Information About Your CalFresh Benefits - CalFresh Water Pilot, CF 304B (9/20) -Notice Of Approval For The CalFresh Water Pilot, CF 304C (9/20) - Notice Of Discontinuance For The CalFresh Water Pilot, CF 304D (10/22) - Notice Of CalFresh Water Pilot Extension, CF 377.1 (5/20) - Notice Of Approval For CalFresh Benefits, CF 377.1LP (5/20) - Notice Of Approval For CalFresh Benefits, CF 377.1A (8/21) - Notice Of Denial Or Pending Status, CF 377.1A LP (8/21) - Notice Of Denial Or Pending Status, CF 377.11 (6/18) - CalFresh Time Limit Notice - Failure To Meet The Able-Bodied Adults Without Dependents (ABAWDs) Work Requirement, CF 377.11A (6/18) - CalFresh Time Limit Notice - Expiration Of Three Consecutive Months For Able-Bodied Adults Without Dependents (ABAWDs), CF 377.11B (6/18) - CalFresh Countable Month Letter - Use Of Countable Month For Able-Bodied Adults Without Dependents (ABAWDs), 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 (1/20) CalFresh Able-Bodied Adult Without Dependents (ABAWD) Time Limit Exemption Screening Form, 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 SAR (6/13) - CalFresh Notice Of Change For Semi-Annual Reporting Households, CF 377.4A (2/14) - CalFresh Notice Of Change (Non-Citizen), CF 377.4 CR (1/14) - CalFresh Notice Of Change For Change Reporting Households, CF 377.5 SAR (9/13) - CalFresh Mid-Certification Period Status Report, CF 377.5A (2/20) - Drug Addiction Or Alcoholic Treatment And Rehabilitation Centers And Group Living Arrangements: Periodic Resident Report, CF 377.5B (1/20) - Drug Addiction Or Alcoholic Treatment Centers And Group Living Arrangements: Change Report For Departing Residents, 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 Disqualification, CF 377.7B (4/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B LP (2/18) - CalFresh Overissuance Notice - Inadvertent Household Errors (IHE) Only, CF 377.7B1 (10/17) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice, CF 377.7B1 LP (2/18) - CalFresh Repayment Notice - Inadvertent Household Errors Only Final Notice, 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 (2/18) - CalFresh Repayment Final Notice - County Administrative Error (AE), CF 377.7D3 (10/17) - CalFresh Overissuance Notice For Administrative Errors (AE), CF 377.7D3 LP (6/18) - CalFresh Overissuance Notice For Administrative Errors (AE), 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), 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), 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, CF 385 (2/23) - Application For Disaster CalFresh, CF 386 (2/14) - CalFresh Notice Of Missed Interview, CF 387 (5/14) - CalFresh Request For Information, CF 388 (8/13) - CalFresh Notice Of Restoration Approval, CF 389 (2/14) - Notice Of Denial Of Restoration, CF 390 (5/19) Notice of Approval/Denial For Disaster CalFresh, CF 478 (2/14) - Disqualification Consent Agreement CalFresh Program, CF 502 (2/23) -Notice To All CalFresh Recipients - End Of CalFresh Emergency Allotments, CF 842 (2/14) - Claim Determination Worksheet, CF 886 (8/22) - CalFresh Notice Of Work Rules, CF 1239 (12/20) - CalFresh Notice Of Approval/Denial/Termination Transitional Benefits, CF 6177 (10/22) - CalFresh Student Exemption Screening Form, 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, CL 1 (4/99) - Cal-Learn Registration Program Information Orientation Appointment, CL 2 (4/99) - Cal-Learn Program Requirements, CL 3 (4/99) - Cal-Learn Notice Of A Participation Problem, CL 4 (4/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant, CL 8 (3/99) - Cal-Learn Notice Of Report Card Submittal Schedule, CL 9 (3/99) - Cal-Learn Notice Of Good Cause Determination, CL 10 (4/99) - Cal-Learn Notice Of Exemption/Deferral, CL 11 (4/99) - Cal-Learn Notice Of Incomplete Grades, CL 15 (1/00) - Cal-Learn Case Management Information Intercounty Transfer Form, CL 16 (1/00) - Cal-Learn Case Management Inter-County Transfer Summary, CR 6181 (11/20) - Interpreter Services Statement And Confidentiality Agreement, CRF 01 (10/20) - Coronavirus Relief Fund (CRF) Certification Of Eligibility, 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 2.1 N A (8/04) - Notice And Agreement For Child, Spousal And Medical Support, CW 4 (6/02) - Immediate Need Payment Request, CW 5 (7/01) - Veterans Benefits Verification and Referral, 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 10 (7/01) - Notice of Withdrawn Application, CW 13 (9/02) - Caretaker Relative Agreement, CW 23 (3/00) - Senior Parent Statement Of Facts, CW 25 (7/01) - Supplemental Statement of Facts - Minor Parent, CW 25A (2/13) - Payee Agreement For Minor Parent, CW 40 (3/00) - CalWORKs - Reduced Income Supplemental Payment Request, CW 42 (10/21) - Statement of Facts - Homeless Assistance, CW 43 (3/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant, CW 51 (10/11) - Child Support - Good Cause Claim For Noncooperation, 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 60 (5/01) - Release Of Information - Financial Institution, CW 61 (7/01) - Authorization to Release Medical Information, CW 63 (11/20) - Request For Income And/Or Resource Verification, CW 71 (3/00) - Statement Of Cash Aid Mother An Unrelated Adult Male (UAM), CW 74 (9/19) - Permanent Housing Search Document, CW 80 (2/18) - Self-Certification Form For Motor Vehicles - CalWORKs, CW 82 (3/00) - Coversheet - Agreement To Sell Property, CW 86 (10/21) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program, CW 87 (6/02) - Reinforming Letter/Add a Person(s)Program, CW 88 Coversheet (6/11) - You May Be Eligible For Diversion Services, CW 88 Coversheet (4/21) - You May Be Eligible For Diversion Services, CW 88 (6/11) - Diversion Services Agreement CalWORKs Program, CW 88 (4/21) - Diversion Services Agreement CalWORKs Program, CW 89 (2/03) - Application Withdrawl Request, CW 101 (7/17) - CalWORKs Immunization Rules, CW 103 (11/09) - Multilingual - Transitional Medi-Cal, CW 215 (10/19) - Notification Of Intercounty Transfer, CW 371 (7/01) - Referral To Local Child Support Agency (LCSA), CW 377 (2/23) - CalWORKs Informational Notice - Potential Intentional Program Violation (IPV), CW 801 (11/00) - Summary Report Of Performance Incentives For Grant Reductions Due To Employment Earnings And Diversion For The California Work Opportunity And Responsibilities To Kids (CalWORKs), CW 801.2 (2/00) - California Work Opportunity And Responsibility To Kids (CalWORKs) Diversion Grant Summary, CW 1725 (10/20) School Attendance/Enrollment Verification, CW 2103 (6/16) - Reminder For Teens Turning 18 Years Old, CW 2166 (7/19) - Multilingual Work Really Pays! 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