WBA Web Files Forms
5/01/2009
Form Number
#2 CAF / Client Assistance Fund
Application
Name
Category
Social Work
Request for Vendor Payment of Rent
Pick-up Slips
Physician's Letter re: In-Home Care
Statement Under Penalty of Perjury
App Summary
Letter to Commanding Officer
Court Notification
Application
Eligibility Applications
Eligibility Applications
Eligibility Applications
Benefit Issuance
Benefit Issuance
Employability/Disability
Verifications
Benefit Issuance
Verifications
Benefit Issuance
Benefit Issuance
Benefit Issuance
Eligibility Applications
Supportive Services
Employability/Disability
Verifications
Other
Verifications
Verifications
40-15
Letter Re: Responsibility of Relative Questionnaire
Eligibility Applications
40-16
Monthly Verification of Earnings
Income Reports & Verifications
40-2
Pregnancy Verification Statement
Verifications
40-20
Step Parent Excluded Parent Budget Worksheet
Benefit Issuance
40-21
Statement of Relationship to AFDC Children
Eligibility Applications
40-32
Pregnant Woman Worksheet
Benefit Issuance
40-34
CW Intake Info Sheet
Other
40-42
40-44
Chronological Income Report
Req. for Income
Income Reports & Verifications
Income Reports & Verifications
40-45
School Verifications
Verifications
40-46
Certification of Case Correction – AFDC
Third-Party reviews
40-54
AFDC Supervisory Audit Sheet
Third-Party reviews
40-56
School Verification for AFDC/FC
Verifications
1 IHSS Application
10-13
10-15
10-7
15-1
1931
2186A
25-1
25-13
25-47
25-6
278 LMO
278F
30-47
310
38-4
40-1
40-10
40-12
40-13
5/01/2009
Additional Case Reg
Provider/Session Request Form
Pre Screen
Meds Network Reg.
Screening Sheet
Exemption Request
Vital Statisitics
Overpayment Report
Receipt for Returned Benefits
Special Pick-up
1
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
40-57
AFDC Homeless Assistance Documentation
Eligibility Applications
40-58
Homeless Statement
Eligibility Applications
40-7
40-76
Self-Employed Income Statement
AFDC Overpayment Computation Referral
Income Reports & Verifications
Benefit Issuance
40-78
40-79
40-80
Benefit Issuance
Benefit Issuance
Benefit Issuance
40-82
40-85
40-86
40-88
40-89
CalWORK Exempt/Non-Exempt MAP Worksheet
Direct Deposit Sign Up form
Work Participation Form
Direct Communication Special Notice to Recipient
Payroll
Direct Deposit Foster Care Communication Special
Notice to Recipient Payroll
MFG Mandatory Worksheet
Request for Work Exemption Form
Native TANF
School Attendance Requirement
40-9
42-1
42-10
42-100
42-101
42-11
42-12
42-15
42-19
42-2
42-21
42-24
42-26
42-27
42-3
42-30
42-31
42-32
42-33
42-34
42-36
30 and 1/3 Tracking Form
Self Appraisal
Child Care Referral Authorization
Checklist for WECSP
WECSP Communication Form
Progress Report
GIS Provider/Session Request
Welfare to Work Employer Information
Program Clerk’s Request for SSA2 Update
Child care & Transportation Questionnaire
Child Care Information
Weekly Job Search Report
Mental Health AOD Attendance
Work & Activity Report
Consent to Release Info
WEN Personal Responsibility Agreement
WEN Monthly Attendance/Progress
Child care Information Notice
Mental Health AOD Assessment
MH/AOD Monthly Report (5/98)
Case Review Form
40-81
5/01/2009
2
Benefit Issuance
Benefit Issuance
Eligibility Applications
Employment/Disability
Eligibility Applications
Correspondence
Income Reports & Verifications
Employability/Disability
Supportive Services
Employment Participation
Employment Participation
Employment Participation
Other
Employment Participation
Other
Supportive Services
Supportive Services
Employment Participation
Employment Participation
Employment Participation
Employment Participation
Employment Contracts
Employment Participation
Supportive Services
Employability/Disability
Employment Participation
Third-Party Reviews
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
42-38
42-4
42-41
Community Service Personal Responsibility Agreement
Training Verification Form
Inter-County Transfer- Welfare to Work
Employment Contracts
Employment Participation
Correspondence
42-42
Community service/work experience appt
Welfare to Work Activitiy Change (for community
Service only)
Learning Disability Referral Form for providers
Correspondence
42-43 (3C)
42-44
42-45
42-46
42-48
42-49
42-5
42-50
Employment Contracts
Employability/Disability
Employability/Disability
Employability/Disability
Employability/Disability
Correspondence
Employment Participation
Supportive Services
42-52
42-54
42-58
42-6
42-60
42-70
42-76
42-77
42-79
Learning Disability Providers Request for Payment
Learning Disability Screening
Behavioral Health Screening
60 mos CalWorks referral form
Application for Employment
Mileage worksheet
Authorization to Share and Release Personal and
Confidential Information
SIP VTR checklist
LEP Job Club Appt. Letter
ET/EC Communication Form
Orientation Appt. Eden SSC
Orientation Appointment Letter
WEN Assignment Notice
Employer Linked Scheduling Notice
CSU Assignment Notice
42-80
42-81
42-81
42-84
42-85
SB1104 Core/NonCore Appointment Letter
Santion Communication
Orientation Appt. All SSCs
Assessment appointment
Work Experience Orientation Appt. Ltr.
Correspondence
Sanctions/Disqualifications
Correspondence
Correspondence
Correspondence
42-91
Employment Contracts
42-92
Self-Initiated Program/Vocational Trn Informing Notice
Alameda Co. WTW Program Employability: Social or
Health Issues Self-Appraisal
Employability/Disability
42-93
Program Award Letter
Correspondence
42-94
Gift Card Request Form
Consent to Release Employment Plan to Contracted
Providers
Other
42-96
5/01/2009
3
Employment Participation
Employment Participation
Correspondence
Correspondence
Correspondence
Correspondence
Correspondence
Verifications
Correspondence
Employment Participation
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
42-97
CalWORKs Contracted Vocational Trng. Comm. Referral
Employment Participation
42-98
42-99
42-CL01
42-CL02 - Number listed Twice
42-CL02
42-CL09
42-CL11
42-CL14
43-15
44-77
45-57
50-1
50-10
50-10 CW
50-10 FC
50-10 GA
50-10 MC
50-11
50-110
50-115Q
50-121
Job Search Forms
WEO/CSO Assignment/Referral Letter
Self Appraisal Forms
Bonus/Sanction Info and Worksheet
Inter-Agency Communications
Child Care Parent/Provider Agreement
Consent for Release of Information
Summary of Bonuses and Sanctions
Supervised Job Search
Trust Line Req
Foster Care Need Letter - Relatives
Speed Gram
Verification of Receipt of Aid
Verification of Receipt of CalWORKS
Verification of Receipt of Foster Care
Verification of Receipt of General Assistance
Verification of Receipt of Medi-Cal
Consent for Release of Information
Voter's Reg
Focused Food Stamp Review
Case Update Request
Case Update Request by: Social Worker or Mental
Health Spec
Additional Cardholder
EBT Card and PIN Responsibility Statement
Request For Exemption From EBT
Exemption From EBT Stagger Date
EBT Special Request
EBT Card Request
EBT Card Destruction form
Client Authorization Form for EBT Repayment
EBT Replacement Affidavit
Application Withdrawal Form
Assessment appointment
Mental Health Screening Tool
Referral for Help with SSI App
SSI Advocacy Form
Employment Participation
Employment Participation
Employment Contracts
Benefit Issuance
Supportive Services
Supportive Services
Employment Participation
Benefit Issuance
Employment Participation
Verifications
Correspondence
Correspondence
Verifications
Verifications
Verifications
Verifications
Verifications
Verifications
Eligibility Applications
Third-Party Reviews
Correspondence
50-121
50-122
50-123
50-124
50-125
50-126
50-126A
50-129
50-130
50-138
50-147
50-151
50-162
50-163
50-164
5/01/2009
4
Social Work
Benefit Issuance
Benefit Issuance
Benefit Issuance
Benefit Issuance
Benefit Issuance
Eligibility Applications
Benefit Issuance
Benefit Issuance
Thirt-Party Reviews
Eligibility Applications
Correspondence
Employment Participation
Employability/Disability
Social Worker
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
50-165
50-20
50-20e
50-23 TEMP
50-27
50-42
50-46
50-59
50-61
Name
GA Recipient Mental Health Screening
Case Transfer Routing Slip
Case Routing Transfer Slip (Employment)
GA Mental Health Screening Invitation
TOC Transfer Summary Worksheet
Screening Sheet/Questionnaire
Notice of Applicants/Recipients
Rent Sharing Statement
Pre-App Info
Category
Correspondence
Other
Other
Correspondence
Correspondence
Eligibility Applications
Correspondence
Eligibility Applications
Eligibility Applications
50-65
50-69
Income Verification
Case Request for Audit
Income Reports & Verifications
Third-Party Reviews
50-72
50-79
50-80
Applicant's Statement of Relationship to AFDC Children
UIB Tracking Calendar
Income and Resource Verification Questionnaire
Eligibility Applications
Income Reports & Verifications
Verifications
50-81
50-82
50-85
50-93
50-96
53-1
53-14
53-15
53-2
53-20
53-23
53-24
53-3
53-30
53-31
IEVS Applicant System – County Response Form
Documentation Receipt
Language Preference
AFDC Information Form
Supervisory Eligibility Case Review
Cover Letter: Investigation of Assets
DMV Clearance
Letter Regarding Verification of School Attendance
Investigation of Assets
SIU Civil Demand Letter
SIU Inquiry
Request for Information
FRED Referral
Appeals Preliminary Review
Crime Report
Fair Hearing Information Request/Instruction Aid
Pending/All Aids
Insurance Policy Information Request
Earned Income Investigation
Notice Re: Abandonment of GA Administrative Review
Request
SIU Overpayment Report Instruction
SIU Referral
QA/QC Error Evaluation/Correction
Income Reports & Verifications
Verifications
Language
Eligibility Applications
Third-Party Reviews
Verifications
Third-Party Reviews
Verifications
Verifications
Third-Party Reviews
Third-Party Reviews
Correspondence
Third-Party Reviews
Third-Party Reviews
Third-Party Reviews
53-33
53-36
53-37
53-38
53-39
53-4
53-41
5/01/2009
5
Third-Party Reviews
Verifications
Verifications
Third-Party
Third-Party
Third-Party
Third-Party
Reviews
Reviews
Reviews
Reviews
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
53-42
53-43
53-45
53-46
53-47
Name
Quality Control Request for Case Action
County Quality Control Data Collection
Report of Investigation
IPV Disqualification Worksheet
IEVS IFCN Letter
Category
Third-Party
Third-Party
Third-Party
Third-Party
Third-Party
53-5
56-1
56-5
56-6
Suspected Fraud Referral
Sworn Statements and Tracers
Contact Record
Food Referral
Third-Party Reviews
Benefit Issuance
Other
Benefit Issuance
63-12
Food Stamp IPV Disqualification Report
Sanctions/Disqualifications
63-13
Employment Participation
63-18
FS Work Registration and Job Search
Self Cert. For Legal Immigrants & Auth. For SSA to
Release Information
Eligibility Applications
63-2
Drug and Alcohol Treatment Facility Departure Report
Correspondence
63-27
63-32
63-32A
63-39
63-42
63-42E
63-42H
Tracer Forms
FS Required Neg/Pos Action Form
FS Required Neg/Pos Action Form
Proration Worksheet
ABAWD Verification Form
Verification of FSET Participation
Verification of FSET Participation
Benefit Issuance
Correspondence
Correspondence
Eligibility Applications
Employment Participation
Employment Participation
Employment Participation
63-43
63-45
63-48
63-5
63-50
63-51
63-52
Verification of Participation of Self Initiated Assignment
CFAP/Non-Citizen Determination Worksheet
Student Eligibility Worksheet
F/S Overissuance
Drug Felony Worksheet
Drug & Alcohol F/S Application Cover Sheet
Expedited Services Determination Worksheet
Verifications
Supportive Services
Benefit Issuance
Benefit Issuance
Benefit Issuance
Eligibility Applications
Eligibility Applications
781
782
80-1
80-12
80-21
Attendance Records
Monthly Attendance Reports
Medical Checklist
Screening Questionnaire for Medi-Cal Applicants
LTS LTC Long Term Care (Checklist)
Employment Participation
Employment Participation
Third-Party Reviews
Employability/Disability
Verifications
80-32
M/C app at Health Care Services Agency Facilities
Eligibility Applications
5/01/2009
6
Reviews
Reviews
Reviews
Reviews
Reviews
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
80-35
80-39
80-6
M/C Budget Documentation
PST Warning Denial Notice
Minor Consent Services
Income Reports & Verifications
Correspondence
Eligibility Applications
80-60
Screening Worksheet - Section 1931 (b) Medi-Cal
Income Reports & Verifications
80-65
Medi-Cal Cover Letter
Correspondence
80-7
Health Care Services/P.G. App Disposition
Eligibility Applications
817
Payment Authorizations
Supportive Services
90-10
90-117
90-118
90-120
GA/FSET Participation Requirement
Agreement to Reimburse and Grant of Loan
Supervised Training Rules and Regulations
CHASS Emergency Shelter Voucher
Employment Contracts
Eligibility Applications
Employment Participation
Benefit Issuance
90-134
90-135
Community Housing and Shelter Services (CHASS)
Verification of Drug/Alcohol Participation
Eligibility Applications
Employment Participation
90-136
90-137
90-139H
90-14
90-141
90-142
90-143
90-147
Employability/Disability
Employment Participation
Employment Participation
Other
Sanctions/Disqualifications
Sanctions/Disqualifications
Employment Participation
Correspondence
90-148P
CHASS Participation Requirements and Regulations
Job Search Contact Record
Job Search Contact Record
GA Case Info Update Request
GA Act of Negligence Notice
Good Cause Statement
Placement Information
GA/FSET Program North County Referral Ltr
Alameda County GA/FSET Program Eastmont Referral
Letter
GA/FSET Program Referral Letter - Eden MultiService
Center
90-15
90-151
90-152
Workforce Rules and Regulations
BROU Services Needed Flier
Accommodation Request
Employment Participation
Employability/Disability
Employability/Disability
90-153
Employability/Disability
90-154
General Assistance Mental Health Evaluation
General Assistance Mental Health Evaluation Invoice –
Request for Payment
Employability/Disability
90-155
Homeless Assistance Application (From Drop-Ins)
Eligibility Applications
90-156
90-159 TEMP
General Assistance Application for Homeless Assistance
Time on Aid Group Checklist
Eligibility Applications
Employment Participation
90-15S
Supervised Training Rules and Regulations
Employment Participation
90-148E
5/01/2009
7
Employment Participation
Employment Participation
WebFiles Forms List
WBA Web Files Forms
5/01/2009
90-162
90-19
90-2
90-2 MH
90-200H
90-241E
90-242
90-243
Name
GA Stmt of Fact
Temp Opportunity to Choose GA Employment Services
Part.
GA/FSET Case Update by EC/ET
Medical Statement Dr.'s Confidential Report
Mental Health Clinician's Confidential Report
Workfare Site Att. Report
TB Testing Referral
ABAWD Self Initiated Workfare Requirement
GA/FS Employment & Training Program
Employment Participation
Other
Employability/Disability
Employability/Disability
Employment Participation
Employment Participation
Employment Contracts
Employment Participation
90-28
GA/FSET Packet
Employment Contracts
90-43
90-44A
90-50
90-51
90-55/190-177
90-6
Aid Paid Pending Order
Third-Party Reviews
Language
Employment Contracts
Employment Participation
Eligibility Applications
Employment Participation
Form Number
90-16
Category
Eligibility Applications
90-62
90-63
90-67
Job Search Contract
GA MOU: Drug and Alcohol
CA Reimbursment
Training Attendance Report
Appointment Letter for Training Review in the
Employables Program
Training Program Review Form
Training Program Verification
90-68
90-77
90-8
Education Training Program Participation Requirement
App Affidavit
GA Budget Worksheet
Employment Contracts
Verifications
Benefit Issuance
90-84 All 90-84s E, G H filed as 90-84
GA Medical Evaluation Appt.
Employability/Disability
90-88
90-9
90-9(A)
90-SANHIST
General Assistance Program Health Questionnaire
Landlord Statement
Rent Statement Cover Letter
FSET Sanction History
Employability/Disability
Verifications
Correspondence
Sanctions/Disqualifications
ABCD 239.7A
CalWORKs Notice of Admin Disqualification
Correspondence
ABCD 478A
Disqualification Consent Agreeement
Third-Party Reviews
ABCDM 228
Applicant's Authorization for Release of Information
Eligibility Applications
AFDC Exempt/Non-Exempt Worksheet
Alternative to G.A. Program (AGAP)
Application
5/01/2009
Employment Participation
Employment Participation
Employment Participation
Benefit Issuance
Eligibility Applications
8
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
Annual Medi-Cal Redetermination Forms
Appeals Decisions
Appeals Compliance Action
Appeals Position Statements
Appeals Preliminary Review Packet
Eligibility Applications
Third-Party Reviews
Third-Party Reviews
Third-Party Reviews
Third-Party Reviews
Appointment Letter
Assessment Plan
Audit Information
Authorization to Disclose Individually
Identifiable Health Info
Authorization to Release Confidential
Information
Authorized Representative Form
Correspondence
Employment Contracts
Third-Party Reviews
Bank Account Statements
Birth Verification
CA-30
CA-40
CA 43
CA 5
CA 61 BI
CA 64
CA 74
Cal-Learn Record (Interagency
Communication)
Cal-Learn Record of Bonus/Sanction
CASA Test Scores
Case Narrative
CCP1
CDS 717
CDS 841-C/S Report
CDS Child Support Ref.
CDS Printouts
Child Care Memos
Child Support Check Stubs
Citizenship
Civil Recovery
5/01/2009
Social Work
Social Work
Benefit Issuance
Manual AFDC Budgets
Manual AFDC Budgets
Applicant Choice From Immediate Need
Payment/Expedited Grant
Veterans Benefits Referral
Medical Report
Statement of Citizenship
Permanent Housing Search Document
Income Reports & Verifications
Verifications
Benefit Issuance
Benefit Issuance
Eligibility Applications
Correspondence
Employability/Disability
Verifications
Eligibility Applications
Benefit Issuance
Benefit Issuance
Employment Contracts
Other
Declaration of exemption from trustline registration and
health and safety
Correspondence
School Verification
Verifications
Absent parent/DCSS
Absent parent/DCSS
Benefit Issuance
Supportive Services
Absent parent/DCSS
Verifications
Third-Party Reviews
9
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
CL 1
CL 2
CL 3
CL 4
CL11
Class Schedules
Client Advocate Contract
Client Assistance Fund Affidavit
Community Outreach Questionnaire
CS 909
CSC 30
CSC 35
CSC 31
CSC 36
CSF 13
CSF 14
CSF 15
Name
Cal-Learn Registration Program Information Orientation
Appointment
Cal-Learn Program Requirements
Cal-Learn Notice of Participation Problem
Cal-Learn Notice to Parent/Legal Guardian of Cal-LEARN
Participant
CAL-LEARN Notice of Incomplete Grades
Paternity
Minor Tax Dependent Status Letter
Redetermination Appointment Letter
Employment Verification When Job Ends
Redetermination Mail-in Letter
Authorization for Release of Information
Authorization for Release of Information Authorized
Representative
Category
Benefit Issuance
Correspondence
Benefit Issuance
Benefit Issuance
Employment Participation
Employment Participation
Third-Party Reviews
Social Work
Social Work
Eligibility Applications
Other
Eligibility Applications
Verifications
Correspondence
Eligibility Applications
Verifications
Authorization for Release of Confidential Information
Authorization for Release of Information Financial
Institution
Caretaker Relative Statement
Child Care Receipt
General Affidavit
Diversion Agreement
Employment Questionnaire
Verifications
Verifications
Verifications
Verifications
Eligibility Applications
Employability/Disability
CSF 23
Statement of Gift/Loan
Income Reports & Verifications
CSF
CSF
CSF
CSF
CSF
CSF
CSF
CSF
CSF
CSF
Medical Report Verification of Physical/Mental Incapacity
Special Diet Request
TB Clearance
Request For Insurance Information
Pregnancy Verification
Fair market Value of Vehicle
General Affidavit Continuation
Birth and/or Citizenship Statement
Receipt for Documents
Request for Discontinuance/Withdrawal/Waiver
Verifications
Correspondence
Employability/Disability
Verifications
Verifications
Income Reports & Verifications
Verifications
Verifications
Verifications
Correspondence
CSF
CSF
CSF
CSF
CSF
CSF
17
18
19
2
21
22
24
25
26
27
28
29
2a
3
30
31
5/01/2009
10
Verifications
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
CSF 33
CSF 34
Name
Notice to Self-Employed Individuals
Daily Tip Statement
Category
Correspondence
Correspondence
CSF 35
Income Reports & Verifications
CSF 36
CSF 37
CSF 39
Self-Employment Sworn Statement
Transportation Cost for Self-Employment or Graduate
Student
School Attendance Verification
CSF 37 School Attendance Verification
Supportive Services
Verifications
Verifications
CSF 4
CSF 40
Birth Declaration
Referral for Education Assessment Services
Verifications
Supportive Services
CSF 41
CSF 43
Referral for Employment Services
Scheduled Hearing
Supportive Services
Correspondence
CSF 44
Withdrawal of Request for a County Hearing
Correspondence
CSF 46
CSF 47
Immunization Status Record
Housing Statement/ Verification
Verifications
Verifications
CSF 49
Request for Verification of Immunization
Verifications
CSF
CSF
CSF
CSF
CSF
CSF
Student Income Verification Request
SFIS Referral
Supervisor Review Form
Payment Receipt
EBT Request for DAC/AR
EBT Exemption from Cash Benefit Stagger Request
Verifications
Supportive Services
Third-Party Reviews
Verifications
Benefit Issuance
Benefit Issuance
Electronic Benefit Transfer (EBT) Exemption for Cash
Electronic Benefit Transfer (EBT) Card and PIN
Responsibility Statement
CalWORKs Contract General Agreement
Notice of Withdrawn Action
Support Questionnaire/Child/Spousal and Medical
Support Notice and Agreement
Notice And Agreement For Child, Spousal And Medical
Support
Support Questionnaire
Notification Of Intercounty Transfer
Maximum Family Grant MFG Rule for Recipients of Cash
Aid
CalWorks and WtW Time Limit Exemption
Request/Determination
Your CalWORKs 60-Month Time Limit
Benefit Issuance
50
55
62
63
64
65
CSF 66
CSF 67
CW 1
CW 10
CW 2.1
CW 2.1 N A
CW 2.1Q
CW 215
CW 2102
CW 2186A
CW 2187
5/01/2009
11
Benefit Issuance
Eligibility Applications
Eligibility Applications
Absent parent/DCSS
Absent parent/DCSS
Absent parent/DCSS
Correspondence
Eligibility Applications
Eligibility Applications
Correspondence
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
CW 2188 (04/02)
Name
Verification of Aid for the TANF Program
CW 2190A
CW 22
CalWORKs 60-Month Time Limit Extender Request Form Eligibility Applications
Sponsor's Statement of Fact's, Income and Resources,
Cash Aid And/Or FS
Eligibility Applications
CW 23
Supplemental Statement of Facts Senior Parent/legal
Eligibility Applications
CW 25
CW 25A
Supplemental Statement of Facts -Minor Parent
Payee Agreement for Minor Parent
Eligibility Applications
Eligibility Applications
CW
CW
CW
CW
CW
371
4
40
42
5
Referral To Local Child Support Agency (LCSA)
Immediate Need Payment Request
Reduction Income Supplement
Statement of Facts Homeless Assistance
Vet. Benefits Referral
Absent parent/DCSS
Eligibility Applications
Income Reports & Verifications
Eligibility Applications
Verifications
CW
CW
CW
CW
CW
CW
CW
51
60
61
61A
61B
63
64
Child Support, Good Cause Claim For Noncooperation
Release of Info Financial Institution
Medical Reports
Physical Capacities
Mental Capacities
Income and Eligibility Verification Form
A Save
Absent parent/DCSS
Verifications
Employability/Disability
Employability/Disability
Employability/Disability
Income Reports & Verification
Verifications
Monthly Eligibility Report
Statement of AFDC Mother and Unrelated Adult Male
(URAM)
Sponsor's Monthly Income & Resources Rpt
Senior Parent Monthly Income Report
Statement of Facts for Additional Persons
Lien Agreement
Agreement to Sell Property
Agreement - Restricted Account, CaIWORKS Program
Diversion Services Agreement
Application Withdraw Request
Statement Of Facts To Add A Child Under 16
Disposition Sheets
Income Reports & Verifications
CW 7
CW 71
CW 72
CW 73
CW 8
CW 81
CW 82
CW 86
CW 88
CW 89
CW 8A
DA
Daily Activities Questionnaire
Daily Activities Questionnaire - Third
Party Information
DC 2
DED Forms
5/01/2009
Category
Verifications
Verifications
Income Reports & Verification
Income Reports & Verification
Eligibility Applications
Eligibility Applications
Eligibility Applications
Eligibility Applications
Eligibility Applications
Correspondence
Eligibility Applications
Third-Party Reviews
Social Work
Social Work
IAAP Letter
Employment Participation
Employability/Disability
12
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
Degree Requirements
Employment Participation
DEP-1002s
DEP-208
DEP-209
DEP-210
DFA 285
Evaluation Form for Mental Distorders
Seizure Questionnaire
Pain Questionnaire
Fatigue Questionnaire
Application For Food Stamp Benefits
Social Work
Social Work
Social Work
Social Work
Eligibility Applications
DFA 285-A1
Application For Food Stamp Benefits
Eligibility Applications
DFA 285-A2
Statement Of Facts
Eligibility Applications
DFA 285-A3QR
DFA 303
Food Stamp Benefits Your Rights And Responsibilities
FS Replacement Authorization
FS Household Change Report
FS Notice of Administrative Disqualification
FS IHE Repayment Notice
FS IHE Repayment Agreement
Eligibility Applications
Third-Party Reviews
Income Reports & Verifications
Correspondence
Correspondence
Verifications
DFA 377.7E
Food Stamp Repayment Agreement
Benefit Issuance
DFA 377.7E1
DFA 377.7F
FS Repayment Agreement for Administrative Errors Only Benefit Issuance
FS IHE to IPV NOA
Correspondence
DFA 377.7G
FS IPV Repayment Agreement
Verifications
DFA 385
DFA 842
Application for Emergency Food Stamp Assistance
Claim Determination Worksheet
Eligibility Applications
Benefit Issuance
DFA 874
DFA 874 Statewide Intercounty Lost Warrant Affidavit
Income Reports & Verifications
DHCS 0003
Affidavit of Reasonable Effort to get Proof of Citizenship DRA Documents
DHCS 0004
DHCS 0005
DHCS 0009
Request for California Birth Record
Receipt of Citizenship or Identity Documents
Proof of Citizenship or Identity needed for Medi-Cal
Applicants and Beneficiaries who are U.S. Citizens or
Nationals
Affidavit of Identity for U.S. Citizens or National
Children Under 18
DHCS 0010
Affidavit of Identity for U.S. Citizens or Nationals for
Disabled Individuals Living in Institutional Care Facilities DRA Documents
DFA
DFA
DFA
DFA
377.5
377.7A
377.7B
377.7C
DHCS 0006
5/01/2009
13
DRA Documents
DRA Documents
DRA Documents
DRA Documents
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
DHCS 0011
DHS 6110
DHS 6155
Name
Category
Proof of Acceptable Citizenship or Identity
Med. Insurance
Health Insurance Questionnaire
DRA Documents
Verifications
Eligibility Applications
DHS 6166
Medi-Care Buy-In Problem Report
Third-Party Reviews
DHS 6168
Potential Third Party Liability Notification
Third-Party Reviews
DHS
DHS
DHS
DHS
Health Insurance Premium Payment Referral
Property Lien Referral
Screening Worksheet (pickle)
Financial Eligibility Worksheet
Verifications
Verifications
Income Reports & Verifications
Income Reports & Verifications
Pickle Needs Test
Disregard Computation w/s
A Medical Report on Adult with Allegation of Human
Immuno-Deficiency Virus
Medical Verification - AIDS
Medical Report on Child with Allegation of Human
Immuno-Deficiency Virus
Worker Observations/Disability
Responsibilities of Public Guardian/ Conservators or
Applicant/ Beneficiary
Notice Regarding Transfer of Home
Dept. of Developmental Svcs Waiver Referral
Income Reports & Verifications
Income Reports & Verifications
6172
7014
7020
7021
DHS 7025
DHS 7029
DHS 7035
DHS 7035
DHS 7035 C
DHS 7045
Verifications
Verifications
Verifications
Verifications
Authorized Representative
Conditional Withdrawal Form
Correspondence
Eligibility Applications
Third-Party Reviews
Other
Employment Participation
Benefit Issuance
Third-Party Reviews
Request for Administrative Disq Hearing
Disqualified Recipient Report
IEVS/PVS Response
Deceased Persons Response
Third-Party
Third-Party
Third-Party
Third-Party
ECS 155
EDD verifications
Fair Hearing Report
Abstract
FC 4
AFDC Program Choice Indicator
Income Reports & Verification
Income Reports & Verifications
Third-Party Reviews
Correspondence
FS 26
Food Stamp Program Qualifying Drug Felon Addendum
Immigration and Naturalization Service Document
Verification Request
GA Hearing Request
DHS 7068
DHS 7077
DHS 7096
Dictation Sheets
Diplomas and Certifications
DPA 19
DPA 315
DPA
DPS
DPS
DPS
435
524
526
528
G845
GA 239H
5/01/2009
14
Reviews
Reviews
Reviews
Reviews
Eligibility Applications
Verifications
Third-Party Reviews
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
GA FSET Denial Request
Name
Category
Eligibility Applications
GA Health Questionnaire
GA Vendor Form
GAES Ancillary Request
Employability/Disability
Verifications
Supportive Services
GAES Negligent Act (Sanction History)
GAIN Communication
GCLM Printouts
Sanctions/Disqualifications
Employability/Disability
Supportive Services
Correspondence
Benefit Issuance
GIS-604
Grant Adjustments
HA-4486
HA-501-U5
Healthy Families
Homeless Mail Not Picked Up
Housing Authority
Welfare to Work Need Letter
Claimant's Statement When Request for Hearing is Filed
& Issue is Disability
Social Work
Request for Hearing by Administrative Law Judge
Identification
IEV 410 Report
IEVS Closure Dictation
IHSS Income Eligibility - Adult
IHSS Services IN-FORM
IHSS - NOA
Income Documentation
Invoices and Receipts for Employment
Support
IPV Dictation
IPV Disqualification Worksheet
IPV's
KG 2
Verifications
Applicant IEVS Response Form
01
13
14A
17
MC 171
5/01/2009
Verifications
Third-Party Reviews
Eligibility Applications
Eligibility Applications
Correspondence
Income Reports & Verifications
Supportive Services
Third-Party Reviews
Third-Party Reviews
Third-Party Reviews
Verifications
Kin Gap Statement of Facts
Master Job Application
MC
MC
MC
MC
Social Work
Eligibility Applications
Correspondence
Supportive Services
Employment Contracts
Authorized Rep Designation & Auth. For Release of Info. Verifications
Statement of Citizenship
Eligibility Applications
QMB/SLMB
Benefit Issuance
Mail in Application
Eligibility Applications
Medi-Cal LTC Admission & Discharge Notification
15
Verifications
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
MC
MC
MC
MC
MC
Medi-Cal Notice to Providers Clarification of Liability
TMC Transitional MediCal Status Report
SOC Determination MFBU w/o LTC Person
Correspondence
Verifications
Income Reports & Verifications
Property Worksheet
Qualified Medicare Beneficiary (QMB) Referral
Eligibility Applications
Verifications
MC 176 S
MC 176 W
Medi-Cal Status Report
Allocations/Special Deduction Worksheet B
Income Reports & Verifications
Income Reports & Verifications
MC 177
Share of Costs
Eligibility Applications
MC 179
Information Request
Correspondence
MC 180
Eligibility Letter of Authorization
Correspondence
MC 194
Social Security Administration Referral Notice
Verifications
MC 210
MC 210A
MC 210PS
Statement of Facts
Facts of Retroactive Coverage/Restoration
Property Supplement
Eligibility Applications
Eligibility Applications
Eligibility Applications
MC 210S1
Income in Kind/Housing Verification
Verifications
MC 210 S-C
MC 212
Additional Child App
Medi-Cal Residency Declaration
Eligibility Applications
Eligibility Applications
MC 213
Verifications
MC 219
Statement of Rent Receipt from a Relative (Q-One)
Request for Withdrawal and/or Waiver ofTen Day
Advance Notice
Important Information for Persons Requesting Medi-Cal
(Rights & Responsibilities)
Eligibility Applications
MC 220
MC 221
Authorization for Release of Information
LA Disability Determination and Transmittal
Other
Eligibility Applications
MC 221
OAK Disability Determination and Transmittal
Eligibility Applications
MC 222
DED Pending Information Update
Correspondence
MC 223
Supplemental Statement of Facts for MC
Eligibility Applications
MC 226
Applicant Prucol Notification Letter (LTC/RD)
SN-2 Sneede v Kizer Excluded Child Statement from
Parent or Caretaker Relative
Sneede v Kizer Excluded Child Statement from Parent or
Caretaker Relative
Redetermination For Medi-Cal Beneficiaries (Long-Term
Care in Own MFBU)
Correspondence
174
176
176M
176P
176QMB-3
MC 215
MC 239 SN-2
MC 239 SN-3
MC 262
5/01/2009
16
Eligibility Applications
Income Reports & Verifications
Income Reports & Verifications
Eligibility Applications
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
MC 272
MC 273
SGA Worksheet
Work Activity Report
Income Reports & Verifications
Employment Participation
MC 274 TB
Application for MediCal Tuberculosis Program
Eligibility Applications
MC 306
Appointment of Representative
Eligibility Applications
MC 321
Additional Family Members Requesting Medi-Cal
Eligibility Applications
MC 322
Real & Personal Property
Eligibility Applications
Request for Transitional Medi-Cal (TCM) OR Four Month
Continuing Medical-Cal
Eligibility Applications
Newborn Referral for Medi-Cal
Birth Verifications
MC 325
MC 330
MC 360
MC 368
MC 4026
MC 61
Notification Of Intercounty Transfer
Notice and Supplemental Form for Express Enrollment
Applicants
Req for Elig Limited Services
Medical Report
Eligibility Applications
Eligibility Applications
Employability/Disability
MC 80-63
Medi-Cal T.B. Program Screening Worksheet
Income Reports & Verifications
MC 845 G-845
Supplement Prucol
Eligibility Applications
Medical Verification and Correspondence
NA 832
Child care NOA from R&R's
NA 9
Employability/Disability
Supportive Services
Right to Request a Fair Hearing
Need Letter
Newborn Automatic Number Assignment
(NANA)
NHR
NOA
Correspondence
Third-Party Reviews
Correspondence
Employment Contracts
New Hire Match
Verifications
Correspondence
NONC Notices
Notes
Sanctions/Disqualifications
Social Work Notes
One EAPP
Other
Other
Other
Other
Other
Other
Other
Eligibility Applications
Absent parent/DCSS
Benefit Issuance
Correspondence
Eligibility Applications
Employment Contracts
Employability/Disability
Employment Participation
5/01/2009
17
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Other
Other
Other
Other
Other
Other
Name
Category
Income Reports & Verifications
Language
Other
Sanctions/Disqualifications
Supportive Services
Third-Party Reviews
Other
Verifications
Other Income Verification
Income Reports & Verifications
Overpayment information
Benefit Issuance
Physician's Evaluation Form
Verifications
Pregnancy Verification
Verifications
Property Documentation
PVS 040
QA Review
Verifications
Verifications
Third-Party Reviews
Payment Verification System
QR 3
QR 30
Reporting Changes For Your Cash Aid Assistance Unit
And Food Stamp Household
Applicant Financial Test
Mid-Quarter Status Report For Cash Aid And Food
Stamps
CalWORKs Budget Worksheet
QR 7
Quarterly Eligibility/Status Report
Income Reports & Verifications
QR 73
Senior Parent Quarterly Income Report
RCA Notice of No Good Cause Determination and
Conciliation Appointment
Income Reports & Verifications
QR 2
QR 29
RCA
RCA 43
RCA 44
RCA Notice of Participation Problem
RCA Notice of No Good Cause Determination and
Compliance Plan Appt.
Income Reports & Verifications
Benefit Issuance
Income Reports & Verifications
Benefit Issuance
Eligibility Applications
Eligibility Applications
Employment Participation
Referral Letter
Refugee Cash Assistance Application
Summary
Rent Receipts
Other
Verifications
REP Assessment Information
Requests for Sanctions
Benefit Issuance
Sanctions/Disqualifications
Resume/Master Application
Returned IFCN Employer Letter
Returned Homeless Mail
Employment Contracts
Income Reports & Verifications
Correspondence
5/01/2009
Correspondence
18
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
Returned Mail
Other
RS 1
REP Assessment Information
Employment Participation
RS 18
Employment Participation
RS 30
Refugee Services - Information Transmittal
Explanation of Mandatory Work Registration
Requirements
Eligibility Applications
RS 3
RS 36
Central Intake Unit (CIU) Referral/Notification
Employment and Training Requirements for RCA
Eligibility Applications
Eligibility Applications
RS-3A
Client Tracking Forms
Supportive Services
RS-SAV103-R001
Systematic Alien Verification For Entitlements
Third-Party Reviews
Santos Outreach
SAWS 1
SAWS 2
SAWS 2A
SAWS 2A QR
SCC7
Schools and Training Providers
Correspondence
Scratch Budgets
SFIS Documentation
SOC 310
SOC 341
SOC 451
Application For Cash Aid, Food Stamps, And/Or MediCal/State CMSP
Statement of Facts for Cash Aid, Food Stamps, And/Or
Medi-Cal/State CMSP
Important Information For Cash Aid, Food Stamps,
And/Or Medi-Cal/State CMSP
Rights, Responsibilities and Other Important
Information For the Cash Aid and Food Stamp
Programs, And/Or Medi-Cal/State CMSP
Childcare
Other
Eligibility Applications
Eligibility Applications
Eligibility Applications
Eligibility Applications
Verifications
Employment Participation
Benefit Issuance
Third-Party Reviews
Eligibility Applications
Social Work
Eligibility Applications
SOC 807 (07/00)
IHSS Statement of Facts
Report of Suspected Dependent Adult/Elder Abuse
CAPI Supplemental App. Form
CAPI Request for Waiver of O/P RecoveryIncome/Expenses
SOC X-5A
IHSS Pickle & SOC Referral
Eligibility Applications
SP 2
Special Investigations
SS 8572
DAPD Disability Determination
Correspondence
Third-Party Reviews
Social Work
Suspected Child Abuse Report
SSA 1 Printouts
Eligibility Applications
Supportive Services
SSA-16-F6
Application for Disability Insurance Benefits
Social Work
SSA-3368-BK
Disability Report - Adult
Social Work
5/01/2009
19
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Name
Category
SSA-3369-BK
Work History Report
Social Work
SSA-3373-BK
Privacy Act and Paperwork Reduction Act Statements
Social Work
SSA-3375-BK
Child Birth to 1st Birthday
Social Work
SSA-3376-BK
Child Age 1 to 3rd Birthday
Social Work
SSA-3377-BK
Child Age 3 to 6th Birthday
Social Work
SSA-3378-BK
Child Age 6 to 12th Birthday
Social Work
SSA-3379-BK
Child Age 12 to 18th Birthday
Social Work
SSA-3441-BK
Disability Report - Appeal
Social Work
SSA-3441-F6
Reconsideration Disability Report
Social Work
SSA-3820-BK
Disability Report - Child
Social Work
SSA-4814-F5
Medical Report on Adult with Allegation of HIV
Social Work
SSA-561-U2
Social Work
SSA-789-U4
Request for Reconsideration
Request for Reconsideration - Disability Cessation Right to Appear
Social Work
SSA-8000-BK
Application for SSI
Social Work
SSA-827
SSI Care Review
SSI Claims Lead
SSI Reimbursement
Authorization to Disclose Info to the SSA
Social Work
Employability/Disability
Social Work
Employability/Disability
SSP 14
Statement of Facts
System Printouts
TB Testing Information
Temp 2131
Temp 2145
Auth for Reimbursement of Interim Assistance Initial
Payment Postelig. Payment
Eligibility Applications
Eligibility Applications
Benefit Issuance
Employability/Disability
Eligibility Applications
Eligibility Applications
Temp 2201
CalWORKs Child Care Eligibility Report
Cash Aid/FS EBT Request for Designated Alternate Card
Holder/Auth Rep.
Benefit Issuance
Temp 2201-A
FS EBT Request for An Authorized Representative
Eligibility Applications
Temp 2203
Request for Cash Aid EBT Exemption
EBT Important Information - EBT Responsibility
Statement
Benefit Issuance
Temp 2215
Temp 2226
TOA 42
Transcripts & Grades
5/01/2009
New Rules for HA for persons elibible for Cash Aid
Time on Aid Review Checklist
20
Correspondence
Eligibility Applications
Benefit Issuance
Employment Participation
WebFiles Forms List
WBA Web Files Forms
5/01/2009
Form Number
Transportation Request Form
Name
Category
Supportive Services
Utility Bills
Verification of Participaton in a Self
Initiated Workfare
Verifications
Verification SSI App
Wage Stubs
Warrant Replacements
Employability/Disability
Income Reports & Verifications
Benefit Issuance
WBUG Screen Printouts
Other
WCAS Printouts
WISE Dictation Printouts
Other
Other
WPER Printouts
Other
Employment Participation
WPR 1
WPR Questionnaire
Employment Participation
WPR 2
Employment Participation
WPR 3
WPR Communication Form
Employment Services Dept. Checklist for WPR Case
Sample Pull
Employment Participation
WTW 1
Welfare to Work Plan Rights and Responsibilities
Employment Contracts
WTW 10
Correspondence
WTW 13
Request for Welfare to Work Third Party Assessment
WTW/Cal-Learn Supportive Services
Overpayment/Underpayment Notice
WTW/Cal-Learn Supportive Services Repayment
Agreement
Welfare to Work/Cal-Learn Supportive Service
Overpayment Final Notice
WTW
WTW
WTW
WTW
WTW
WTW
WTW
Simplified fS Program
Learning Disability Waiver
Learning Needs Screening
Welfare to Work Plan Activity Assignment
Consent to Release Learning Disability Info
Good Cause Form
Plan to Stop WTW Sanction
Employment Participation
Employability/Disability
Employability/Disability
Employment Contracts
Employability/Disability
Sanctions/Disqualifications
Employment Contracts
WTW 3
Welfare to Work Plan Activity Assignment Change
Employment Contracts
WTW 31
Request to Stop WTW Sanction
Employment Contracts
WTW 32
WTW 4
WTW Compliance Plan
Employment Contracts
Notice to other parent
Correspondence
WTW 6
Welfare to Work Exemption Request
Employability/Disability
WTW 11
WTW 12
15
17
18
2
20
27
29
5/01/2009
21
Employment Contracts
Employment Contracts
Employment Contracts
WebFiles Forms List
WBA Web Files Forms
5/01/2009
WTW 8
Name
Welfare to Work Exemption Determination
Student Financial Aid Statement Welfare to Work
Supportive Services
Supportive Services
WTWCC
109 CW Employment/Self-Sufficiency Plan
Employment Participation
Form Number
WTW 7
5/01/2009
22
Category
Employability/Disability
WebFiles Forms List