cdss forms spanish

Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. 6. 48 close to the numerical solution and major trends of the well BHP and average . Get ready-made fillable templates for faster form filing and decrease human errors. Search. 3. . Spanish - NOA will be issued in Spanish. Every child maltreatment case under s. 39.30 (1) is to be reported and a report made by a child maltreatment case manager or a designee of the child maltreatment case manager with the information or records to . 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 (1/23) - 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 (3/23) - The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, EFA 15 (3/23) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2023Income 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. FCCH - Pre-Orientation Registration Information: Wait! **Due to browser constraints please download forms for full functionality. Tips for Using Adobe PDF Files. This document is for reference purposes only, may not be comprehensive, and is subject to change depending on federal and state statutes and . Questions and comments are moderated. California Foster Youth Education Law Fact Sheets in Spanish (PDF) The Foster Youth Definitions (XLSX) document provides reference information on the educational supports and entitlements for foster youth. California State Forms Directory. For personal information access requests, send an email to CDSS Public Inquiry and Response Unit piar@dss.ca.gov and/or call (916) 651-8848. ATTORNEY OR PARTY WITHOUT ATTORNEY . For more information, review the online CDSS Privacy Policy Statement. Problems with downloading forms? Confidential Referral/Follow-Up Report - PM 161. You must complete an Electronic Theft of Cash Aid Form within 90 days from the electronic theft transaction in order for food or cash benefits to be replaced. PDF fill-and-print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an . Tips for Using Adobe PDF Files, Notice of Action Documents(used by county governments), Copyright 2023 California Department of Social Services, NA Back9 (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412), NA Description Of Services L (3/15) - Description Of services, NA IHSS Back L (3/15) - Your Hearing Rights, NA 200 (12/20) - Notice Of Action - Multipurpose - Include Budget, NA 200 (7/21) - Notice Of Action - Multipurpose - Include Budget, NA 210 (5/20) - Discontinue, Suspend Financial Eligibility, NA 213 (10/21) - Deny - Financial Eligibility, NA 213A (12/20) Notice Of Action Deny Financial Eligibility, NA 213A (7/21) Notice Of Action Deny Financial Eligibility, NA 214 (4/00) - Discontinue, Suspend Transfer of Property, NA 215 (1/00) - Continuation Page, Sponsor Non Citizens Deemed Income, NA 216 (11/99) - Sponsored Non Citizens Property, NA 271 (12/20) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid, NA 271 (7/21) - Notice Of Action - Continuation Page - Family Income Computations - Cash Aid, NA 274 (4/99) - Continuation Page Overpayment Computations (prior to 10-1-89), NA 274B (4/99) - Continuation Page Overpayment Computations (for 10/1/89 to 8/31/91), NA 274C (4/99) - Continuation Page - Overpayment Computations (for 9/1/91 to 8/31/95), NA 274D (1/00) - Continuation Page - Overpayment Computations (Ortega 9/1/95 to 12/31/97), NA 274E (6/11) - Notice Of Action Overpayment Computations For 1-1-98 to 6-30-2011, NA 274F (6/11) - Notice Of Action - Overpayment Amount Owed (For Overpayments Occurring On Or After 7/1/2011), NA 274G (7/19) - Notice Of Action - Continuation Page - Overpayment ComputationsOccurringOn Or After10/1/2013, NA 274H (12/20) - Notice Of Action - Continuation Page - Overpayment Computations Between 6/1/2020 and 05/31/2021, NA 274I (7/21) - Notice Of Action - Continued - Overpayment Amount Owed For Overpayments Occurring Between 6-1-2021 and 5-31-2022, NA 274J (7/21)-Notice of Action Continued - Overpayment Amount Owed For Overpayments Occurring On or after 6-1-2022, NA 275 (4/99) - Continuation Page - Overpayment Adjustment Computation - Cash Aid, NA 277 (1/00) - Continuation Page Optional Persons Transfer of Property, NA 278 (1/00) - Discontinue/Suspend Optional Persons Transfer of Property, NA 279 (1/00) - Excess Property (with Good Faith), NA 280 (1/00) - Excess Property (w/o Good Faith), NA 281 (6/11) - Notice Of Action - Underpayment Amount Owed (For Underpayments Occurring on or After 1-1-98 thru 6-30-2011), NA 281A (6/11) - Notice Of Action Underpayment Amount Owed (For Underpayments Occurring On Or After 7/1/2011), NA 281B (5/13) - Notice Of Action Continuation Page - Underpayment Computations On Or After 10/1/2, NA 281C (7/19) - Notice Of Action - Continuation Page - Underpayment Computations Occurring On Or After 6/1/2020, NA 281C (12/20) - Notice Of Action Continuation Page - Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2020 and 5-31-2021), NA 281D (7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring Between 6-1-2021 and 5-31-2022), NA 281E(7/21) - Notice Of Action (Continued) Underpayment Amount Owed (For Underpayments Occurring On Or After 6-1-2022), NA 290 (2/14) -Notice Of Action - Multipurpose, NA 300 (7/19) - Notice Of Action - Continuation Page - Recipient Financial Eligibility Test, NA 300 (10/21) - Notice Of Action - Continuation Page - RecipientFinancial Eligibility Tests, NA 301 (10/21) - Continuation Page - Applicant Financial Eligibility Test, NA 403 (2/23)- Notice Of Action - Approval, Change or Discontinued - For Resource Families, Including Homes Certified By AFoster Family Agency, County Approved Relative Homes, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians, Intensive Treatment Foster Care and/or Intensive Services Foster Care, Group Homes and Short-Term Residential Therapeutic Programs, NA 403A (4/17) - Notice Of Action Approval, Change Or Discontinued For Kinship - Guardians Only, NA 421 (6/21) Assistance Dog Special Allowance (ADSA) - Notice Of Action - Approval, NA 422 (11/21) - Assistance Dog Special Allowance (ADSA), NA 422L (1/22) -Assistance Dog Special Allowance (ADSA) Notice of Action Denial, NA 530 (4/11) - Notice Of Action -48-Month Time Limit, NA 530 (4/21) - Notice Of Action - 60-Month Time Limit, NA 531 (12/20) - Notice Of Action - Continuation Page-48-Month Time Limit- Includes Budget, NA 531 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget, NA 531 (7/21) - Notice Of Action - Continuation Page - 60-Month Time Limit - Includes Budget, NA 532 (7/19) - Notice Of Action - Continuation Page - 48-Month Time Limit Discontinue, NA 532 (12/20) - Notice Of Action - Continuation Page - 48-Month Time Limit Discontinue - Includes Budget, NA 532 (4/21) - Notice Of Action - Continuation Page - 60-Month Time Limit Discontinue - Includes Budget, NA 532 (11/21) - Notice Of Action- Continuation Page - 60-Month Time Limit Discontinue - Includes Budget, NA 691 (3/18) - Notice Of Denial - Cash Assistance Program For Immigrants (CAPI), NA 692 (12/17) - Notice Of Change - Cash Assistance Program For Immigrants (CAPI), NA 693 (9/22) - Notice Of Approval - Cash Assistance Program For Immigrants (CAPI), NA 791 (9/18) - Notice Of Action - Approval/Denial/Change, NA 816 (3/14) - Notice Of Action - Sanction Of Other Parent After Failed Compliance Plan, NA 817 (3/14) - Notice Of Action - Sanction Of Participant After Failed Compliance Plan, NA 818 (3/14) - Notice Of Action - Taking You Out Of Welfare To Work, NA 820 (1/01) - Notice Of Action - Transportation Approval, NA 821 (1/01) - Notice Of Action - Transportation Approval/Denial, NA 822 (7/16) - Notice Of Action - Transportation Change, NA 823 (8/00) - Notice Of Action - Ancillary Expenses Approval/Denial, NA 825 (8/00) - Notice Of Action - Payment Adjust Transportation, NA 827 (7/99) - Notice Of Action - Recoupment Unused Advance Payment, NA 828 (7/99) - Notice Of Action - Transportation And Ancillary Exp Overpayment, NA 832 (3/20) - Notice of Action - Child Care Services, NA 833 (4/20) - Notice of Action - Child Care Services Change, NA 834 (3/20) - Notice of Action - Child Care Services Denial, NA 835 (3/20) - Notice of Action - Child Care Services Discontinuance, NA 840 (3/14) - Notice Of Action - Welfare To Work Plan, NA 840A (10/03) - Notice Of Action - Determination Of Good Cause/No Good Cause, NA 841 (3/14) - Notice Of Action - Welfare-To-Work Plan, NA 843 (6/99) - Notice Of Action - Ineligible, NA 844 (8/99) - Notice Of Action - Adequate Progress, NA 845 (3/14) - Notice Of Action - Sanction and Removal Of The Other Parent's Needs, NA 960X SAR (9/13) - Notice Of Action - Stop Aid;Report Not Received, NA 960Y SAR (10/14) - Notice Of Action - Stop Aid;Report Incomplete, NA 991 (10/03) - Notice Of Action - Refugee Cash Assistance (RCA)/Entrant Cash Assistance (ECA) MC-Decrease/Expiration (Time-Expiration), NA 992 (5/03) - Refugee Cash Assistance (RCA) Application Approval, NA 994 (11/00) - Food Stamp Notice Of Discontinuance (Failure to Meet Non-Assistance CFAP Work Requirement (Violation Prior To Three Consecutive Month Grace Period), NA 995 (5/13) - Food Stamp Notice of Denial/Disqualification For The California Food Assistance Program, NA 996 (11/00) - Food Stamp Notice Of Discontinuance (Failure to Meet Non-Assistance CFAP Work Rule (Violation After Receipt Of Three Consecutive Month Grace Period, NA 1209 (2/02) - Notice Of Action - Change In The Amount Of Kin-Gap Payment, NA 1210 (4/02) - Notice Of Action - Discontinue, NA 1211 (2/00) - Notice Of Action - Denial, NA 1212 (2/00) - Notice Of Action - Discontinue Property, NA 1213 (2/00) - Notice Of Action - Discontinue Restricted Account, NA 1214 (2/00) - Notice Of Action - Change Under/Overpayment, NA 1217 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice of Overpayment, NA 1218 (9/22) - Notice Of Action - Cash Assistance Program For Immigrants - Notice Of Underpayment, NA 1230 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Approval, NA 1231 (9/22) - Cash Assistance Program for Immigrants Notice of Overpayment - Partial Waiver Approval, NA 1232 (2/21) - Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Denial, NA 1233 (3/02) - Notice Of Action - Multipurpose, NA 1239 AR (12/20) - Notice Of Action - Continuation Page - Annual Reporting Budget, NA 1239 AR (8/21) - Notice Of Action - Continuation Page - Annual Reporting Budget, NA 1239 SAR (12/20) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget, NA 1239 SAR (8/21) - Notice Of Action - Continuation Page - Semi-Annual Reporting Budget, NA 1240 (4/13) -Notice Of Action - Food Stamp Overissuance & Dormant EBT Account, NA 1250 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Approval, NA 1250L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval, NA 1251 (5/09) -Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation, NA 1251L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Approval Continuation, NA 1252 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Denial, NA 1252L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Denial, NA 1253 (11/12) - Notice Of Action In-Home Supportive Services (IHSS) Change, NA 1253L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change, NA 1254 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation, NA 1254L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Change Continuation, NA 1255 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Termination, NA 1255L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Termination, NA 1256 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cost, NA 1256L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Share Of Cost, NA 1257 (5/09) - Notice Of Action In-Home Supportive Services (IHSS) Multi, NA 1257L (3/15) - Notice Of Action In-Home Supportive Services (IHSS) Multi, NA 1261 (1/16) - Notice Of Action - Form and Instructions - For Group Homes, Short-Term Residential Treatment Centers, Foster Family Agencies, Transitional Housing Placement-Plus Foster Care and Transitional Housing Placement Program, NA 1261A (3/20) - Notice Of Action For Approved Relatives, Non-Relative Extended Family Members, Foster Family Homes, Non-Related Legal Guardians or Non-Minor Dependents Residing In A Supervised Independent Living Setting, NA 1261B (1/16) - Notice Of Action - Form And Instructions - For Kinship-Guardians Only, NA 1263 (8/11) - Notice Of Action - Overissuance Budget Worksheet, NA 1267 (4/13) - CalFresh Informing Notice Of Receiving Intercounty Transfer, NA 1268 (4/13) - CalFresh Informing Notice Of Sending Intercounty Transfer, NA 1269 (11/11) - Notice Of Action - Approve Non-Minor Dependent, NA 1270 (11/11) - Notice Of Action - Discontinue Non-Minor Dependent, NA 1271 (5/14) - Notice Of Action - Denial Of Home Assessment/Approval, NA 1273 (7/13) - Electronic Notification Agreement, NA 1274 (7/13) - Electronic Notification Notice, NA 1275 (7/13) - Electronic Notification Cancellation Notice, NA 1276 (1/15) - Notice Of Action - Welfare-to-Work 24-Month Time Clock Limit Notice, NA 1277 (1/16) - Notice Of Action - Approved Relative Caregiver (ARC) Overpayment, NA 1278 (11/16) - Notice Of Action - Approve Approved Relative Caregiver (ARC) Payment, NA 1279 (5/22) Notice of Action Deny Approved Relative Caregiver (ARC) Payment, NA 1280 (5/22) Notice of Action Discontinue Approved Relative Caregiver (ARC) Payment, NA 1281 (11/16) - Notice Of Action - Change Approved Relative Caregiver (ARC) Payment, NA 1282 (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay, NA 1282L (12/19) - Notice Of Action In-Home Supportive Services (IHSS) Overpayment - Advance Pay, PI 2 (6/15) - IRS Office Of Safeguards Data Incident Report, PUB 13 (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California, PUB 13L (5/22) - Your Rights Under California Public Benefits Programs - For People Applying For Or Receiving Public Aid In California, PUB 56 (12/06) - The In-Home Supportive Services Program, PUB 69 (5/22) - County Forms Catalog2021-2022, PUB 104 (12/06) - In-Home Supportive Services Individual Provider Benefits and Services Information, PUB 190 (8/06) - How To Hire And Supervise Your In-Home Supportive Services (IHSS) Provider, PUB 203 (1/04) - In-Home Supportive Services - Guide to Workers Compensation Benefits for Individual Providers. Family members residing in the home are three adults (licensee, and 2 adult renters who utilize the separate section of the house property . Privacy Notice on Collection PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing. Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Spanish, Tagalog, Vietnamese. State of CaliforniaHealth and Human Services Agency . The following resources are provided for program recipients/consumers. The CWDs/Agencies may modify these forms 1952 chevy station wagon; rusty key order of the flaming rose; Venta. Collection of this information is required to deliver the specific services, but use of these services is voluntary. Form Adopted for Mandatory Use Judicial Council of California ICWA-020 [Rev. SOC 2302 (Spanish) (4/18) Page 1 of 2 PROGRAMA DE SERVICIOS DE APOYO EN EL HOGAR (IHSS) FORMULARIO DE SOLICITUD DEL PROVEEDOR PARA PAGO POR AUSENCIA REQUISITOS DEL PROVEEDOR: Solamente puede solicitar pago por enfermedad si ha acumulado pago por ausencia por enfermedad. View Screenshot 2023-04-06 12.02.47 PM.png from SPANISH 2 at United High School. Medi-Cal Personal Injury Program. IHSS is considered an alternative to out-of-home care, such as nursing homes or board and care facilities. CDSS Licensing Administrative Action Personnel Flagging Attachment ; LIC 9015 (9/00) - Legal Case Transmittal ; LIC 9020 (5/17) - Register Of Facility . Health Insurance Premium Payment Program. . PUB 387 (5/09) - California Electronic Benefit Transfer (EBT) Card - The easy, safe, and convenient way to receive your food stamp benefits. When Spanish or Chinese forms are completed the SW must: Manually enter the referral number, client name(s) and allegation information Import the completed form into CWS/CMS. Child Abuse or Severe Neglect Indexing Form This form is for use by government agencies mandated to . Translations: Spanish IHSS/WPCS retailer who have general questions about Direct Deposit can call the IHSS Serve Desk during store hours at 1-866-376-7066. If you answered "YES" to both Question #1 AND #2, respond to Questions #3 and #4 below, and complete the certification in PART D at the bottom of the form. (DHCS), California Department of Social Services (CDSS) and/or the County in which I receive services. AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California. Annual Report of Hearing Testing - PM 100. Individuals who provide personal information to CDSS have the right to review the information for accuracy and completeness and to request corrections or deletions. DGS PD 14-001 Sub-Purchase Order Link opens a document. On 3/2/2023, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1-Year inspection at the Velasco Family Child Care.Upon arrival, the LPA met with the licensee, Bertha Velasco, who guided the LPA on a tour of the facility. D Forms. Spanish - California Department of Social Services - CA.gov CDSS forms and publications are available only in Portable Document Format (PDF). Medi-Cal Eligibility Divisi on forms are listed below, alphabetically, by form number and has been translated into Spanish. textbook form 21-22.pdf. Japanese. PUB 403 (1/13) - English and Spanish - We Accept EBT - EBT Retailers Posters ; PUB 403A (1/13) - English and . The following person helped me to fill out this form: Name and relationship to applicant Address Date . Welfare and Institutions Code section 10850. Purchasing Authority Change Request (PACR) Link opens a document. Person referred to INS to obtain replacement documents. dobitie kreditu tesco mobile. 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 Please do not post private or sensitive information such as names, addresses, phone numbers, emails, confidential financial and legal details. or b. eneficiary name: Mailing . Korean. . chania webcam airport; Servicios de desarrollo Inmobiliario. MC 200 Forms: MC 209 (05/12) - Changes to your Medi-Cal coverage during your pregnancy and after you give birth. MC 210 A (09/07) - Supplement to Statement of Facts for Retroactive Coverage/Restoration. Lic 9108 Form is not the form you're looking for? Follows CDSS plan and Code of Conduct system daily. The Department of Social Services has free forms and publications that can provide you with information and guidance in a number of important areas. . El propsito de las visitas y las cartas es asegurar que los requisitos del Programa se estn cumpliendo y que los servicios autorizados sean necesarios para que usted permanezca en su hogar de una manera segura. Quality Assurance Fee Program. 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 100 (11/20) - Examples Of Verification, GEN 111 (11/20) - Employer Statement Form, GEN 788 (3/22) - Request To Stop My Benefits, GEN 788LP (3/22) - Request To Stop My Benefits, 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 126 (3/21) - Entrance Checklist - Family Child Care Homes, 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 9121 (7/21) - Facility Visit Checklist Family Child Care, 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. 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