See the Authorized Representative Payee Chart. lx}I=u1\=VrN!F\UlRpDRhO|#s9c^l~3e;12qCqB*.3P-J=*S=+OeD^_ ,rZ HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb Posted on June 29, 2022 in gabriela rose reagan. In this field, a Medical Release of Information Authorization Form will be required to have the documents of the patient. illinois obituaries 2020 . EMC A: . /Tx BMC The Information to be Released. Recertification CF37 . AD 933 (12/20) - Intercountry Readoption Acknowledgment. /Tx BMC Case number (optional) Date . NOTE: Some links on this page are documents in Adobe . 9A~c+e!0Ow ;3`yKn:nSL5)@~rMBEr~u8pAYh="4e3&X\6H(Tzzop|kUM.Mwcfe FKJj6 B^v n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega. its regulations and 1034 0 obj <>stream DATE . csf 14 authorization for release of information authorized representative. Problems with downloading forms? E' p ?564'>nn;XU|YEnZ=[{1"if$@XN=>kJU:pJA^ ?3[p$~at:T4{:n1}j 3w q.m,IU:h#BcQ~)U!!W"Y6Gt Zs2v-Sz :n7c+@1EbPCM,y~~YH?z&x1oo (:~ g/^v;]OZI\f(BqJlB7hK~$ Rv bZ}uz@pv_0Q H / CHECK ONE Patient Parent Domestic csf 14 authorization for release of information authorized representative. SAWS 2 Plus:Application forCalFresh, Cash Aid, and/or Medi-CalCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CF 285: Application for CalFresh BenefitsCambodian, Chinese,Farsi,Spanish,Tagalog, Vietnamese, Other languages, CF 37: Recertificationfor CalFresh BenefitsCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CCFRM604: State of California Health Insurance ApplicationCambodian,Chinese, Farsi, Spanish,Tagalog,Vietnamese, Other languages, 90-16:Application for General Assistance, SOC 814:Statement of Facts Cash Assistance Program for Immigrants (CAPI)Chinese, Spanish, Other languages, 90-152:GA Accomodation RequestSpanish,Cambodian,Chinese,Farsi,Vietnamese, SAR 7:Eligibility Status ReportCambodian, Chinese, Farsi, Spanish,Tagalog,Vietnamese,Other languages, SAR 3: Mid-Period Status Report For Cash Aid and CalFreshCambodian, Chinese,Farsi, Spanish,Tagalog,Vietnamese,Other languages, CalWORKs, CalFresh, Refugee Cash Assistance, and General AssistanceCSF 14: Authorization for Release of Information - Authorized Representative, Medi-CalMC 382: Appointment of Authorized RepresentativeCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, MC 383: Authorized Representative Standard Agreement for Organizations, CAPIC-776:CAPI Authorized Representative Form. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= This authorization expires on _____, or six (6) (DATE) months from the date of signature, whichever is sooner. Clients must complete a DSHS 14-532 AREP form when designating a new AREP. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 AMedical Authorization Formmay be completed by the administering physician to acquire the medical records of his patient. The following forms need to becompleted duringfortheMedi-Calapplicationprocess. Bs!}\H_`./0Bs! endstream endobj startxref Legal Guardianship is designated by coding the AREP screen Rep Type field in ACES with the following: Power of Attorney for cash, medical, and basic food is designated by coding the AREP screen Rep Type field in ACES with AD or NA. The following formsneed tobecompletedduringforthe GA applicationprocess. EMC Nuestro personal est altamente cualificado. % DSBlank endstream endobj 888 0 obj <> endobj 889 0 obj <>/Subtype/Form/Type/XObject>> stream endstream endobj 224 0 obj <> endobj 225 0 obj <>/DA(/Helv 0 Tf 0 g)/F 4/FT/Sig/MK<<>>/Rect[69.0621 355.183 467.077 371.112]/StructParent 7/Subtype/Widget/T(Applicant/Beneficiary's signature)/TU(Please enter the Applicant/Beneficiary's signature)/Type/Annot>> endobj 226 0 obj <>/DA(/Helv 0 Tf 0 g)/F 4/FT/Sig/MK<<>>/Rect[66.8903 104.562 267.71 120.056]/StructParent 10/Subtype/Widget/T(Authorized representative's signature)/TU(Enter the Authorized representative's signature)/Type/Annot>> endobj 227 0 obj <>/Subtype/Form/Type/XObject>> stream H|n@,SEKlp5i"o93vtEew~iyL7{l4MW_jpymf_y>qli|?O]0w2GlH6tyW?wKYX~bcdo9gL[^KQ (m6 K%%@IX H\Mj0>37"),CFq}0 "i>*w _5zOp>?`,TfFg:{LoKDg*~>s4%.S $1?i43Rl"r'g%-c To order forms, complete the form at the bottom of this page. Health Insurance Premium Program (HIPP) Application. Photocopies of this authorization shall be considered as valid as an original. 77 0 obj <>/Encrypt 68 0 R/Filter/FlateDecode/ID[<7505846DAAB7146F6DCE917783904669><3A94F331270E8948AED6D6D48DFB54A6>]/Index[67 36]/Info 66 0 R/Length 64/Prev 84923/Root 69 0 R/Size 103/Type/XRef/W[1 2 1]>>stream CF 31 (4/15) - CalFresh Supplemental Form For Special Medical Deductions. Building partnerships and connections through outreach, giving, and volunteering. Authorized Representative/ HIPAA Form PLEASE PRINT CLEARLY * This information is mandatory. _gL7YG{b>v#F>//C1n taqOY__5UUeKZ\Uq2~?&Ymn J?4y/*Eue!~VUYTqZy?6u=gD Nx>mp ((J,8p Fh El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega.La persona asignada para el proceso de Apostilla en los distintos Ministerios, Cmaras, Colegios y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, Nuestro personal est altamente cualificado. %PDF-1.6 % Decide on what kind of signature to create. hb```"oV)af`0p &I0nafX4AD?P`YJD!NMV$2F3{i1 032p040060`}Pht@/ABo].T.`FY?R~04\.zd'&?Jl| @ H/M A(pQ!R(PRBEe8R$d,J8JNM6-q Medical and healthcare agencies. %PDF-1.7 % EMC 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 - 42th Month On Aid, CW 2189B (9/20) - Notice Of Your CalWORKs Time Limit 57TH Month On Aid (Use Starting May 1, 2022), CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form, CW 2190B (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 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 (7/19) - 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 2218 (6/21) - 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 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 (6/19) - 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 - Intentional Program Violation (IPV), 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 Agreement For An Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Disqualification, DFA 377.11B (11/00) - Food Stamp Notice Of Continuance, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, 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/CalFresh, 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 (BI) (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 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC). they receive. The 14-012(x) is the correct form for authorizing the sharing of specified confidential information between specified parties for a specified period of time. hbbd```b``"VH2H&c&d,i &YH%91 DH2.g&"+&{*.a`$:F@ PP Form . 14-532 Authorized Representative Author: Brombacher, Millie A. n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. SSP 14 Authorization for Reimbursement of Interim AssistanceChinese, Spanish, 90-117 County of Alameda Lien FormSpanish, CW 2223 Demographic QuestionnaireChinese, Spanish, 50-123 EBT Card and PIN Responsibility Statement, 90-88 General Assistance Program - Health QuestionnaireSpanish, 90-151 Informed Consent for Health QuestionnaireChinese,Spanish, 90-251 CalFresh Employment & Training Program Option to Participate, 90-54 Important Notice to GA Applicants, SAR 7 SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian, Chinese, Farsi, Spanish, Tagalog, Vietnamese, YAE General Information Notice for the Young Adult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, OAE General Information Notice for theOlderAdult Expansion Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Alameda County Social Services Agency Home, CalWORKs Initial Application and Redetermination forms, CalFresh Initial Application and Renewal forms, General Assistance (GA) Initial Application and Renewal Application forms, Cash Assistance Program for Immigrants (CAPI) Initial Application forms. The Alameda County Social Services Agency provides resources and opportunities in a culturally responsive manner to enhance the quality of life in our community by protecting, educating, and empowering individuals and families. 2. calfresh forms csf 14 authorized representative calfresh calfresh proof of income . Medi-Cal MC 382: Appointment of Authorized Representative Cambodian, Chinese , Farsi, Spanish, Tagalog, Vietnamese MC 383: Authorized Representative Standard Agreement for Organizations. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 # @`"PT {5@\jM+| sI 67 0 obj <> endobj 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. See WORKER RESPONSIBILITIES. 9L $? U When to require the DSHS 17-063 authorization form or HCA 80-020 authorization for the release of information form. 6m5q'b` HX$a c @55| /MS9 2020 (e) (7); 7 C.F.R. 63-61 CalFresh Employment & Training Brochure, SAR 7 SAR 7 Eligibility Status Report Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, SAR 7 Addendum Instructions And Penalties SAR 7 Eligibility Status Report - For Cash Aid and CalFreshChinese,Farsi,Spanish, Tagalog,Vietnamese, SAR 7A How To Fill Out Your SAR 7 Eligibility Status ReportCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, EBT 2216 EBT Surcharge Free Direct DepositHandout Cambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 13 Your Rights Under California Public Benefits Programs - For People ApplyingForOrReceiving Public AidInCaliforniaCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, PUB 275 Family Planning- Making the Commitment for Healthy FutureCambodian, Chinese, Spanish,Vietnamese, PUB 524 Protect Your Benefit - Beware of Skims and Scans. HR(PD" Name . CDSS forms and publications are available only in Portable Document Format (PDF). endstream endobj startxref 0 %%EOF 887 0 obj <>/Metadata 39 0 R/PageLayout/OneColumn/Pages 67 0 R/StructTreeRoot 74 0 R/Type/Catalog/ViewerPreferences<>>> endobj 934 0 obj <> stream Notable exceptions to the rule are as follows: a. xwpw#8N.d'6nN,z1yN.Xz[cgN}'P X EBT 2259: Report of Electronic Theft of Benefits. AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. The client can identify an AREP on the application, eligibility review form, or DSHS 14-532 authorized representative form. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- nQt}MA0alSx k&^>0|>_',G! The Public Disclosure Unit is responsible for approving or denying requests for disclosure of confidential information. Medi-Cal Eligibility Divisi on forms are listed below, alphabetically, by form number and has been translated into Spanish. %%EOF /%9TB!:(zQRN HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb 961 0 obj <> endobj CF 32 (6/13) - CalFresh Request For Contact. Create your signature and click Ok. Press Done. $uH-tH(CjGolH#6J0m0.&X}0Ls cWo { EMC endstream endobj 891 0 obj <>/Subtype/Form/Type/XObject>> stream Document extensions or changes to the designated AREP in ACES. CF 29D (2/14) - CalFresh Recertification On-Demand Appointment Letter. 3013d100Hh>pY^?)~|P- 9& Generally, only a patient may authorize release of his/her medical information. The DSHS 17-063 authorization form and the HCA 80-020 authorization for release of information form are HIPAA compliant forms designed for use by the client to authorize the release of existing documents to a specified individual or agency. endstream endobj 898 0 obj <> stream 29/06/2022 . 269 0 obj <>stream *{PK\RL-/i=,~6%2yT'EN5e IN2ZNdb9K;5> When the information is needed from DSHS to administer a DSHS program and get needed services to a client (example; verification for a child care provider; however, only share information that would be necessary for the provider to provide child care). endstream endobj 962 0 obj <>/Metadata 32 0 R/Pages 959 0 R/StructTreeRoot 67 0 R/Type/Catalog/ViewerPreferences<>>> endobj 963 0 obj <>/MediaBox[0 0 612 792]/Parent 959 0 R/Resources 986 0 R/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 964 0 obj <>stream Check the AREP information coded in ACES at each review. Both the client and Alternate Card Holder must complete and sign the DSHS 27-130 form. }3$@JAt " ]YL /@ > %PDF-1.6 % Review these documents as they have important information regarding your application. HIPAA restrictions prevent us from discussing the client's individual health information with an AREP unless a current signed DSHS 14-012(x) consent form is in the record. AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement . csf 14 authorization for release of information authorized representative. The name, address, contact numbers, and date of birth are the common information found on this section. 1B114F All Forms N/A Authorization for Release of Information Authorized Representative CSF 14 506481 Reason Code County Category NOA Action Document Name Number Template 300001 Placer Forms Affidavit to N/A Obtain Duplicate Warrant All 662 609763 300001 Santa Barbara Forms N/A Affidavit to Obtain Duplicate of Lost or endstream endobj 229 0 obj <> stream endstream endobj 231 0 obj <> stream N')].uJr FDU 113 (7/22) - Civil Rights Annual Training Checklist For CSFP And TEFAP, FS 31 ENG/CH (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 111 (11/20) - Employer Statement Form, 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 Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider, 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 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) 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 (8/21) - 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 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 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 279 (2/09) - Application For A Family Child Care Home License, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, 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 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 301E (10/22) - Reference Request - Exemption, 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 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 702 (8/08) - Child's Preadmission Health History - Parent's Report, 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 995E (10/09) - Caregiver Background Check Process, LIC 995F (10/09) - Caregiver Background Check Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, 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 9163 (3/21) - Request Live Scan Service - Community Care, 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 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9227 (8/20) - Individual Infant Sleeping Plan, M16-120B (6/11) - EBT Dormat Account: Suspend, M16_120C (7/02) - EBT Dormant Account - Reactivate, M16_325B (7/02) - EBT Incomplete Document, M16-325E (8/08) - Direct Deposit Cancellation, M16_505A (7/02) - Designated Alternate Cardholder, M16_505B (7/02) - Designated Alternate Cardholder - Need Additional Fact, M16_505D (7/02) - Designated Cardholder - Deny, M20-003 (7/01) - Duplicate Aid Match, Discontinue, M20-003A (7/01) - Duplicate Aid Match, Deny, M20-353C (6/98) - Fraud, Penalty Applied to AU, M20-353D (6/98) - Fraud, Penalty Applied to AU, M20-353F (6/98) - Fraud, Penalty Stops - Change, M40_105 (11/14) - Failed to Provide SSN When Received or Failure to Cooperate, M40_105A (11/14) - Failed to provide SSN or proof of completed SSN Application, M40_105B (7/98) - Change: Required Documentation Received, Immunization, M40_105C (11/14) - Notice of Action - Immunizations, M40_105D (7/98) - Change: Required Documentation Received, School Attendance, M40-105D1 (1/15) - Notice Of Action - School Attendance, M40_105E (2/15) - Notice of Action - School Attendance, M40_105I (3/00) - Deny: SFIS Requirements, Failure to Cooperate, M40_105J (3/00) - Deny: SFIS Requirements, Refusal to Cooperate, M40-107 (6/11) - Addendum 1 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption, M40-107 (4/21) - Addendum 1 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption, M40-107 (6/11) - Addendum 2 - Child Support Collection For CalWORKs 48-Month Time Limit Exemption, M40-107 (4/21) - Addendum 2 - Child Support Collection For CalWORKs 60-Month Time Limit Exemption, M40_107A (11/02) - Other: CalWORKs 60-Month Time Limit, Time on Aid (no previous NOA issued), M40-107A (4/21) - Time On Aid (no previous NOa issued), Other, M40_107B (6/11) - Time on Aid at Redetermination, M40-107B (4/21) - Time On Aid at Redetermination, M40-107C (6/11) - Time On Aid Between 42th and 46th, M40-107C1 (9/20) - Time on Aid Between 54th and 57th Month - Use Starting May 1, 2022, M40-107D (6/12) - Time On Aid To Former CalWORKs Recipients, M40-107D (4/21) - Time On Aid To Former CalWORKs Recipients, M40_107F (6/11) - Extended Beyond 48 Months Of Aid, M40-107F (4/21) - Extended Beyond 60 Months of Aid, M40-107F1 (4/21) - Extender Met After 60th Month, M40_107F1 (6/11) - Extender Met After 48th Month, M40_107G (11/02) - Discontinue: CalWORKs 60-Month Time Limit, 60th month on Aid, M40-107G (4/21) - 60th Month On Aid, Discontinue, M40_107H (11/02) - Change: CalWORKs 60-Month Time Limit, 60th month on Aid MFG child only, M40-107I (7/22) - 60th Month On Aid, No eligible child, Discontinue, M40_107J (11/02) - Partial Approval: CalWORKs 60-Month Time Limit, Time-Out Adult, M40-107J (4/21) - Timed-Out Adult, Partial Approval, M40_107J1 (6/11) - Approval after 48 Months On Aid, M40-107J1 (4/21) - Approval After60 Months on Aid, M40_107K (6/11) - Increase Grant due to TOA Adjustment, M40-107K (4/21) - Increase Grant due to TOA Adjustment, M40_118A (8/96) - Application Processing Deny, M40-125B SAR (4/16) - Restore After a SAR7 Discontinuance, M40-125C SAR (4/16) - Incomplete Semi-Annual Report (SAR7) Denial of Restoration, M40 129B (11/09) - Full Payment - Approve, M40-129B1 (12/90) - Approval after Immediate Need Payment, Approve, M40-129D1 (11/14) - Procedural Requirements, Deny, M40-129D2 (12/90) - Procedural Requirements, Deny, M40-129D3 (12/90) - Procedural Requirements, Deny, M40-129D4 (9/00) - Procedural Requirements, Deny, M40_129D5 (11/14) - Failed to Provide Proof of SSN Application, Deny, M40-171A (11/14) - Failure to Cooperate, Deny, M40-171B (5/91) - Refusal to Cooperate, Deny, M40_171C (6/98) - Approve: Application Processing, Basic Approval, M40_171M (7/87) - Denial: Application Processing, Not a California Resident, M40 181 (9/13) - SAWS 2 Redetermination Of Eligibility, M40-181A (11/14) - SAWS 2 Redetermination/Other Essential Information, M40_181E (11/14) - SAWS 2 PLUS Redetermination Immunizations/School Attendance, Change, M40 181C SAR (9/13) - Notice Of Action - Balderas Reminder Notice, M40-181F (7/22) - No Change at Redetermination, M40-195A (8/22)- ICTNotice Of Transfer, Sending, M40-195B (8/22) - ICT Notice Of Transfer, Receiving, M41_401A (12/86) - Denial: Deprivation, No Deprivation, M41_440F (6/98) - DENY: Deprivation, CalWORKs-U, 100 Hours Work Rule, M41_450A (1/98) - Deprivation: Uniformed services - Deny, M42_101B (11/14) - Age and School Requirements, M42-101C (11/14) - Age and School Requirements, Discontinue, M42 207A (10/15) - Over Property Limit, Deny, M42_221K (4/99) - Suspend: Property, Transfer w/out Fair Consideration, M42_221L (4/00) - Suspend: Income, Transfer w/out Fair Consideration, M42-431A4 (11/14) - No Eligible Noncitizen Status/Proof of Eligible Noncitizen Status, Discontinue, M42-769A (11/14) - Apply $100 Cal-Learn Penalty, M43_119E (1/98) - Sponsored Non-Citizen: Some needs Met - Change, M43_119G (11/14) - Missing SAR 72, Change, M43-119H (11/14) - Missing SAR 72, Discontinue, M43_119I (7/98) - Change: Sponsored Alien, Deemed & Family Property, M43_119J (7/98) - Change: Sponsored Alien, Deemed Property, M43_119K (7/98) - DENY: Sponsored Alien, Deemed Property & Family Property, M43_119L (7/98) - DENY: Sponsored Alien, Deemed Property, M43_119M (1/98) - Sponsored non-Citizen: Deemed Income-Change, M44_113A (6/98) - Change: Income, Change in Income, M44_113G1 (6/98) - Change: Income, Change in Income, M44_133D (6/98) - Change: Income, Change in Income, M44_133Q (6/98) - Change: Income, Change in Income, M44_133S (10/02) - Minor Parent Financial Eligibility (Change), M44-133T (9/20) - Minor Parent, Financial Eligibility, Partial Approval, M44_133V (10/02) - Minor Parent Financial Eligibility (Suspend), M44-207I SAR (4/16) - Financial Eligibility, M44_207J (6/98) - DENY: Income, Financial Eligibility Test, M44_207L (6/98) - SUSPEND: Income, Financial Eligibility Test, M44-207K (5/20) Financial Eligibility, Discontinue, M44-207K1 (5/20) - Minor Parent, Financial Eligibility, M44-207M (8/20) - Financial Eligibility, Deny, M44-211B (10/21) - Expanded Temporary HA For Applicants Fleeing DV, Approve, M44-211D (10/21) - Temporary Shelter And/Or Permanent Housing, M44_211L (7/01) - Change: Special Needs - Pregnancy, M44-211N (9/21) - No Longer Pregnant, Change, M44_305 (9/97) - Minor Parent Change of Payee, M44_307A (11/15) - Voucher/Vendor Payment, Other, M44-315A (5/20) - $10 Minimum Payment, Change, M44-315A (8/21) - $10 Minimum Payment, Change, M44_315B (9/98) - CHANGE: Aid Payment Levels, ICT between Reg-2, M44 315C (4/09) - Notice of Action - Four Percent Grant Reduction, M44 316 (8/04) - No Change/Mid Quarter Reporting, M44 316 SAR (9/13) - No Change/Mid-Period Reporting, M44 316A (9/13) - Notice Of Action - Not Yet Changed, M44 316B (9/13) - Notice Of Action - Change In Income Over IRT, M44-316C (8/22) - Notice Of Action - No Change/Mid-Period Report Of Property, M44 316C SAR (10/17) - No Change/Mid-Period Report of Property, M44 316D SAR (9/13) - Notice Of Action - Change In Income, M44-316E (10/16) - Mid-Period Change Due To The Death Of A Child, M44_340 (4/00) - Approval: Underpayments, Underpayment Adjustment, M44 340C (8/12) - Underpayment Adjustment, M44_350A (11/11) - Overpayment Adjustment, M44_350E (11/11) - Excess Property Overpayment Adjustment (W/O Good Faith), M44_350F (11/11) - Excess Property Overpayment Adjustment (W/O Good Faith), M44_350G (11/11) - Excess Property O/P Adjustment (with Good Faith), M44_350H (11/11) - Excess Property Overpayment Adjustment (With Good Faith), M44-350I SAR (9/13) - Notice Of Overpayment, M44-350J (3/12) - Overpayment To Be Stopped Effective February 1, 2012, M44-350K (11/21) -EBT Replacement Denial, M44_352A (11/11) - Notice of O/P and Demand, M44-352H (11/11) - Overpayment Adjustment, M44 352H SAR (9/13) - Notice Of Action Overpayment Adjustment, M44_401A (6/98) - Approve: Hardship Supplement RISP - MFG, M44_401B (6/98) - Deny: Hardship Supplement RISP - MFG, M81_215A (6/98) - DENY: Aid Payments, Diversion payment provided, M81_215B (6/98) - DENY: Aid Payments, Diversion services provided, M81_215D (6/98) - Change: Aid Payments, Diversion Repayment Stops, M82-506 (6/98) - Change: Assignment of Support Rights, Failure to Cooperate, M82-506A (6/98) - Partial Approval: Assignment of Support Rights, Failure to Cooperate, M82-510 (6/02) - Failure to Cooperate, Change, M82-510A (6/98) - Change: Support Process/Assignment, Cooperate, M82-812 (4/04) - Family Reunification/Zero Grant, M82-820A (9/21) - No Eligible Person, Deny, M82-832A (2/99) - Change: Aid Payments, Fleeing Felons, M82-832B (2/99) - Partial Approval: Application Processing, Fleeing Felons, M82-832E (4/15) - Eligible Person Leaving AU, Change, M82-832F (4/15) - Eligible Person Leaving AU, Discontinue, M82-832G (6/18) - Eligible/Mandatory/Optional Person Leaving AU, M82-832H (10/20) - Child Does Not Meet Requirements (SB 380), M82-836A (8/91) - Denial: Au Composition, Unborn not Eligible for Aid, M89-130 (1/02) - Restricted Account, Discontinue, M89_201 (11/96) - Minor Parent exemption: Deny, MT42_101.2D (11/04) - Fry vs Saenz Lawsuit Age Requirement - Change, MT42_101.2E (11/04) - Fry vs Saenz Lawsuit Age Requirement - Discontinue.
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