Fill - Free fillable Ab12 Acl 11 78 11 78.pdf (California State University, Fresno) PDF form

November 30, 2011

ALL COUNTY LETTER NO. 11-78

TO: ALL COUNTY WELFARE DIRECTORS

ALL COUNTY CALFRESH COORDINATORS

ALL COUNTY CALWORKS PROGRAM SPECIALISTS

ALL COUNTY WELFARE TO WORK COORDINATORS

ALL COUNTY CONSORTIUM PROJECT MANAGERS

ALL COUNTY CHILD WELFARE SERVICES PROGRAM MANAGERS

SUBJECT: CALIFORNIA WORK OPPORTUNITY AND RESPONSIBILITY TO

KIDS: EXTENDING BENEFITS TO NON-MINOR DEPENDENTS

REFERENCE: ASSEMBLY BILL 12 (CHAPTER 559, STATUTES OF 2010);

WELFARE AND INSTITUTIONS (W&I) CODE SECTIONS 11253,

11253.3, 11403, and 11454.5; ALL COUNTY INFORMATION

NOTICE I-40-11; ALL COUNTY LETTER 11-36, 11-61, and 11-69

The purpose of this letter is to inform county welfare departments (CWDs) of changes

to the California Work Opportunity and Responsibility to Kids (CalWORKs) program

pursuant to Assembly Bill (AB) 12 (Chapter 559, Statutes of 2010). The statutory

changes add a new category of youth hereafter referred to as Non-Minor Dependents

(NMDs) eligible to receive CalWORKs benefits up to age 20. Contingent upon

legislative approval, the age limit for the receipt of benefits for NMDs will be extended to

age 21. This letter includes instructions to be used in the implementation of extending

CalWORKs benefits to NMDs.

AB 12 directs the California Department of Social Services (CDSS) to implement the

statute initially through an All County Letter (ACL), followed by regulations to be

developed by July 1, 2012. These CalWORKs changes created by AB 12 go into effect

on January 1, 2012, and will be phased in over a three year period.

REASON FOR THIS TRANSMITTAL

[X] State Law Change

[ ] Federal Law or Regulation

Change

[ ] Court Order

[ ] Clarification Requested by

One or More Counties

[ ] Initiated by CDSS

All County Letter 11-78

Page Two

BACKGROUND

Currently, dependent children placed with relatives who are not eligible to receive

federal or state foster care payments but are still eligible for foster care services, may

qualify for CalWORKs benefits until age 18. Benefits (for all children) continue if the

child is enrolled full time in high school, a vocational or technical training program and

will graduate before reaching age 19.

AB 12 established a new category of NMDs eligible to receive extended CalWORKs

benefits. An NMD is defined as a current dependent child or ward of the juvenile court

who is 18, but less than 21 years of age; is in foster care under the responsibility of the

CWD or county probation department; and is participating in a transitional independent

living case plan.

CalWORKs ELIGIBILITY WORKER (EW) RESPONSIBILITIES

Under AB 12, the NMD is only required to meet at least one of the five AB 12 eligibility

conditions, agree and adhere to the Mutual Agreement (Share of Cost 162), and

cooperate with the six-month review hearings/certification. Program requirements for

the NMD will be managed by the children's services case manager. Once the children's

services case manager has determined the NMD is meeting program requirements, the

children's services case manager will provide documentation of eligibility to the

CalWORKs EW, who will then issue the CalWORKs payment. Continuing

documentation of eligibility by the children's services case manager will occur every six

months.

Upon receiving initial documentation of the NMD's eligibility for extended CalWORKs

benefits from the children's services case manager, the CalWORKs EW will complete

an intraprogram transfer, assign the NMD a new case number and aid code, and place

the NMD in his/her own assistance unit (AU).

ELIGIBILITY

In order to remain eligible for extended CalWORKs benefits, NMDs must be living with

an approved relative caregiver (as determined by the children's services case manager)

who is not eligible for federal or state foster care payments. NMDs may live with needy

or non-needy caretaker relatives. Caretaker relatives will not be eligible for CalWORKs

if the NMD is the only "eligible child." NMDs living with non-related guardians, where

guardianship was established through the probate court (and not through dependency)

are not eligible for extended benefits, pursuant to the terms of W&I Code Sections

11405(e).

All County Letter 11-78

Page Three

Additionally, the NMD must sign a Mutual Agreement form that they are voluntarily

consenting to remain in foster care as a court dependent. The NMD is responsible for

reporting to the children's services case manager changes in placement or other

relevant changes in circumstances that may affect eligibility.

Eligible youth include those who:

 Turn 18 in 2011 and are in foster care dependency on January 1, 2012; or

 Turn 18 in 2012 or later and are in foster care dependency on January 1, 2012;

and

 Are ineligible for either federal or state only foster care payments, but receive

CalWORKs.

Ineligible youth include those who:

 Have terminated court dependency prior to January 1, 2012

 Turn age 19 in 2011

 Are married

 Are in the military

 Are incarcerated

 Are in a non-related legal guardianship through the probate court.

In addition, the NMD must meet one of the following program requirements:

(1) Enrolled in and working towards completing high school or an equivalency

program,

(2) Enrolled at least half-time in post-secondary or vocational school, or enrolling

for the next available term,

(3) Participating in a program or activity that promotes or removes barriers to

employment,

(4) Employed at least 80 hours per month, or

(5) Is incapable of enrollment or participation in school or employment due to a

documented medical (physical, mental, or emotional) condition.

For additional information regarding these requirements, please see ACL 11-69, dated

October 13, 2011.

TIMEFRAMES

Starting January 1, 2012, the maximum age for eligibility benefits will be phased in as

follows:

 Effective January 1, 2012, NMDs are eligible for payments up to 19 years of age.

All County Letter 11-78

Page Four

 Effective January 1, 2013, the age limit is extended to up to 20 years of age for

an eligible NMD.

 Effective January 1, 2014, the extension of benefits for a NMD up to 21 years of

age is contingent upon a funding appropriation by the state legislature.

MUTUAL AGREEMENT

Foster youth must sign a Mutual Agreement with the CWD to acknowledge they are

voluntarily agreeing to remain in foster care in supervised placements as court

dependents. The children's services case manager will be responsible for completing

the Mutual Agreement and providing a copy to the CalWORKs EW.

SIX-MONTH CERTIFICATION OF PARTICIPATION ELIGIBILITY

The children's services case manager must also complete a Six-Month Certification of

Extended Foster Care Participation Form (Share of Cost 161) verifying that the NMD

intends to meet one or more of the five participation activities for extended foster care

during the next six-month period. The certification form will be provided to the EW to

continue eligibility for extended CalWORKs or Aid to Families with Dependent Children

(AFDC)-Foster Care (FC) benefits. This form must be provided by the end of the first

month of the next six-month certification period to avoid a disruption of benefits. In most

cases the certification should be updated at the same time the Transitional Independent

Living Plan (TILP) and case plan are updated for the case review hearing. CalWORKs

EWs are encouraged to develop a process within their counties to ensure that the

needs and requirements of NMDs are being addressed in a timely manner. For those

counties that continue to operate a Linkages program, this may be an appropriate unit

for these cases to be housed.

For additional information regarding the mutual agreement and six-month certification,

please see ACL 11-69, dated October 13, 2011.

CALWORKS REQUIREMENTS

NMDs are not subject to CalWORKs program rules, including Welfare-to-Work (WTW),

or reporting requirements. The NMD is only required to meet at least one of the five

conditions of eligibility established under AB 12, agree and adhere to the Mutual

Agreement, and to cooperate with the six-month review hearings/certification described

above. However, in situations resulting in overpayments (OPs), such as court delays or

late filing of paperwork, an overpayment may be assessed. Notices of Action (NOAs)

and corresponding OP budget computations will be provided under separate cover. As

a reminder, counties have the option to compromise the amount or suspend the

All County Letter 11-78

Page Five

collection of non-fraudulent OPs in the CalWORKs program when it is not cost-effective

to pursue them.

Each NMD will be in his or her own AU of one and will receive the same grant amount

as a non-exempt AU of one. Any statutory changes imposed on the CalWORKs grant

levels shall also be applied to the NMD's grant. Payments will be made directly to the

NMD. The 10-day timeframe for noticing NMDs regarding any changes in their grant

still apply.

PREGNANT OR PARENTING TEENS

All pregnant or parenting teens may establish their own CalWORKs case at age 18 if

otherwise eligible. NMDs have the option to remain a dependent as a NMD, or to

establish their own CalWORKs case. Teens who opt to remain in extended CalWORKs

as a NMD will continue to be subject to the rules established under AB 12 and will

receive cash aid for themselves only. Teens who opt to establish their own CalWORKs

case will then be subject to all of the program and reporting rules under the "regular"

CalWORKs program unless exempt, and will be eligible to receive benefits for both

themselves and their child. WTW requirements for pregnant and parenting teens who

do not have a high school diploma or GED may be found in ACL 11-36, dated April 21,

2011. Regular WTW requirements apply to those who have received their diploma or

GED. These teens/NMDs must continue to be informed of their possible continuing

eligibility options and responsibilities, including WTW program requirements and

sanctions.

OUT-OF-COUNTY

It is not uncommon for youth being served under the foster care program to reside

outside of the county of jurisdiction. The county of jurisdiction retains child welfare

services case management, and payment responsibility for NMDs regardless of what

county the NMD lives in. However, the county of residence may agree to provide

courtesy supervision for the children's services case manager.

CALFRESH BENEFITS

Although the NMD is in his or her own AU, the NMD is still considered to be a boarder in

the relative caretaker’s household for CalFresh purposes. If the CalFresh household

requests that the NMD be included in the household and is otherwise eligible for

CalFresh, the NMD's needs will be included in the determination of eligibility for

CalFresh benefits. A separate allotment will not be assessed for the NMD and placed

on his/her Electronic Benefit Transaction (EBT) card since as a boarder they may not

participate in the program independently of the household.

All County Letter 11-78

Page Six

MEDI-CAL BENEFITS

Medi-Cal eligibility for NMDs does not change. NMDs who continue to receive

CalWORKs will be eligible for full-scope Medi-Cal benefits with no share of cost under

the new aid code 4N (see below) provided they meet the requirements for Medi-Cal

eligibility under the Former Foster Care Children’s program. In order for a child to be

eligible under the Former Foster Care Children’s program, the child must be in foster

care under the responsibility of the State on his/her 18

birthday, be under 21 years of

age, and reside in the State.

AID CODE/FISCAL CLAIMING

Aid code 4N is being established for NMDs receiving extended CalWORKs cash aid.

Due to system complications, the creation of this aid code within the Medi-Cal Eligibility

Data System (MEDS) may not be available upon the January 1, 2012 implementation

date. Until aid code 4N is created in the MEDS system and available for use, counties

must manually track cases utilizing this aid code. Funding for extended benefits to

CalWORKs NMDs is 100 percent state general fund. Fiscal claiming instructions will be

provided in an upcoming County Fiscal Letter. For fiscal claiming questions, please

contact the Fiscal Systems Bureau at fiscal.systems@dss.ca.gov.

NEW AND REVISED FORMS AND NOAs

The Quarterly Report (QR) 2103 (11/11) form REMINDER FOR TEENS TURNING 18

YEARS OLD has been revised to include NMDs. Counties are to send the QR 2103 to

relative caretakers of aided teens 60 days before the teen turns 18 to inform them of

possible continuing eligibility options. The QR 2103 instructs relative caretakers to

provide the notice to teens that are approaching age 18. In addition, two new NOAs

have been created specifically for NMDs. NA 1269 (11/11) APPROVE NON-MINOR

DEPENDENT is to be used to approve extended CalWORKs cash aid to a NMD.

NA 1270 (11/11) DISCONTINUE NON-MINOR DEPENDENT is used to notify the NMD

that extended CalWORKs cash aid will be discontinued and the reason for the

discontinuance. The TEMP NA Back 9 is to be used with both new NOAs. CWDs

should begin using the attached form and NOAs by January 1, 2012.

CAMERA READY COPIES AND TRANSLATIONS

For a camera-ready copy in English, contact the Forms Management Unit at

fmudss@dss.ca.gov. If your office has internet access, you may obtain these forms from

the CDSS webpage a http://www.dss.cahwnet.gov/cdssweb/FormsandPu_271.htm

When all translations are completed per Manual of Policies and Procedures Section 21-

115.2, including Spanish forms, they are posted on an on-going basis on our web site.

All County Letter 11-78

Page Seven

Copies of the translated forms can be obtained at

http://www.dss.cahwnet.gov/cdssweb/FormsandPu_274.htm. For questions on

translated materials, please contact Language Services at (916) 651-8876. Until

translations are available, clients who have elected to receive Spanish, Russian,

Vietnamese, and written Chinese materials should be sent the GEN 1365 interpretation

informing notice with a local contact number.

This ACL is intended to provide a general overview and implementing instructions. A

Question and Answer ACL will follow to address the more complex scenarios

associated with the implementation of AB 12. If you have questions or need additional

information regarding this ACL, please contact Crystal Grant at (916) 653-5192 or the

CalWORKs Eligibility Bureau at (916) 654-1322.

Sincerely,

Original Document Signed By:

TODD R. BLAND

Deputy Director

Welfare to Work Division

Attachments

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REMINDER FOR TEENS TURNING 18 YEARS OLD

Give this notice right away to your child who will be turning 18 years old within the next 60 days.

QR 2103 (11/11) REQUIRED FORM - SUBSTITUTE PERMITTED

If you are 18 years old and don't have children and/or are not pregnant

You can still get cash aid as part of your parent/caretaker's case after your 18th birthday ONLY if you:

● Are a full-time student in high school, or in a

vocational or technical training program, and

are expected to finish school/program before

reaching 19 years old, or

● Are a full-time student in high school, or in a

vocational or technical training program, and

have been or are considered disabled, and

meet the disability criteria pursuant to the

CalWORKs regulations, or

Call your county worker right away if you think you meet any of these situations. If you are eligible to stay on cash aid, you

may need to have a fingerprint and photo image taken by the county.

If you are 18 years old and have a child of your own and/or are pregnant

1. You can continue to get cash aid as part of your parent/caretaker's case after your 18th birthday ONLY if you:

● Are a full-time student in high school, or in a

vocational or technical training program, and

are expected to finish school/program before

reaching 19 years old, or

● Are a full-time student in high school, or in a

vocational or technical training program, and

have been or are considered disabled, and

meet the disability criteria pursuant to the

CalWORKs regulations, or

- OR -

2. You can choose to start your own case. Call your county worker right away if you want to start your own case.

Here are some things you need to know before starting your own case:

● You do NOT have to move out of your

parent/caretaker's home to be in your

own case.

● Your time limits for getting cash aid

will start.

● As the head of your case, YOU must report all

changes to your county worker each Quarter.

If you are under your own case or are a part of your parent/caretaker's case, to be eligible to stay on cash aid, you may need

to have a fingerprint and photo image taken by the county. If you have questions about whether you should start your own

case, call the county welfare office or local legal services office.

● Are a foster child living with an approved relative

and are completing high school or an equivalency

program, enrolling in post-secondary or vocational

school, participating in a program or activity that

promotes or removes barriers to employment,

employed at least 80 hours per month, or unable

to participate in school or employment due to a

documented medical condition.

● Are a foster child living with an approved relative and

are completing high school or an equivalency

program, enrolling in post-secondary or vocational

school, participating in a program or activity that

promotes or removes barriers to employment,

employed at least 80 hours per month, or unable

to participate in school or employment due to a

documented medical condition.

● If you start your own case, your parent or caretaker

may get less cash aid or if you are the only child their

cash aid may be stopped.

● If the Maximum Family Grant (MFG) rule was applied

to your child while you were a dependent minor

parent, your child can be counted in your cash aid

payment when you are in your own case.

● As of July 1, 2011, if you are pregnant and don’t have

other children, you will not be able to get cash aid

until your third trimester. If you were granted cash aid

prior to your third trimester before July 1, 2011, you

will be eligible to continue to receive aid.

STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COUNTY OF

NOTICE OF ACTION -

APPROVAL

Notice Date :

Case

Name :

Number :

Worker

Name :

Number :

Telephone:

Address :

Questions? Ask your Worker.

(ADDRESSEE)

State Hearing: If you think this action is wrong, you can

ask for a hearing. The back of this page tells how. Your

benefits may not be changed if you ask for a hearing

before this action takes place.

Rules: These rules apply. You may review them at your county

welfare office: WIC 11253, AB 12 (Chapter 559, Statutes of

2010).

NA 1269 (11/11) APPROVE NON-MINOR DEPENDENT - REQUIRED FORM - SUBSTITUTE PERMITTED

Page 1 of ____

The County has approved your cash aid. The cash aid payment for

your first month of aid is $______________.

Your first day of cash aid is ____________________.

The cash aid payment for your first month of aid is only for a part of a

month. It is for the time from your first day of cash aid, shown above,

through the end of the month. If nothing changes, your ongoing cash

aid amount will be $______________.

MM/DD/CCYY

If you ask for a hearing before an action on Cash Aid,

Medi-Cal, CalFresh (Food Stamps), or Child Care takes place:

• Your Cash Aid or Medi-Cal will stay the same while you wait for a

hearing.

• Your Child Care Services may stay the same while you wait for a

hearing.

• Your CalFresh (Food Stamps) will stay the same until the hearing

or the end of your certification period, whichever is earlier.

If the hearing decision says we are right, you will owe us for any

extra Cash Aid, CalFresh (Food Stamps) or Child Care Services

you got. To let us lower or stop your benefits before the hearing,

check below:

Yes, lower or stop:

■■ Cash Aid ■■ CalFresh (Food Stamps)

■■ Child Care

While You Wait for a Hearing Decision for:

Welfare to Work:

You do not have to take part in the activities.

You may receive child care payments for employment and for

activities approved by the county before this notice.

If we told you your other supportive services payments will stop, you

will not get any more payments, even if you go to your activity.

If we told you we will pay your other supportive services, they will be

paid in the amount and in the way we told you in this notice.

• To get those supportive services, you must go to the activity the

county told you to attend.

• If the amount of supportive services the county pays while you

wait for a hearing decision is not enough to allow you to

participate, you can stop going to the activity.

OTHER INFORMATION

Medi-Cal Managed Care Plan Members: The action on this notice may stop

you from getting services from your managed care health plan. You may wish

to contact your health plan membership services if you have questions.

Child and/or Medical Support: The local child support agency will help

collect support at no cost even if you are not on cash aid. If they now collect

support for you, they will keep doing so unless you tell them in writing to stop.

They will send you current support money collected but will keep past due

money collected that is owed to the county.

Family Planning: Your welfare office will give you information when you ask

for it.

Hearing File: If you ask for a hearing, the State Hearing Division will set up a

file. You have the right to see this file before your hearing and to get a copy of

the county's written position on your case at least two days before the hearing.

The state may give your hearing file to the Welfare Department and the U.S.

Departments of Health and Human Services and Agriculture. (W&I Code

Sections 10850 and 10950.)

TO ASK FOR A HEARING:

• Fill out this page.

• Make a copy of the front and back of this page for your records.

If you ask, your worker will get you a copy of this page.

• Send or take this page to:

• Call toll free: 1-800-952-5253 or for hearing or speech impaired

who use TDD, 1-800-952-8349.

To Get Help: You can ask about your hearing rights or for a legal

aid referral at the toll-free state phone numbers listed above. You

may get free legal help at your local legal aid or welfare rights office.

If you do not want to go to the hearing alone, you can bring a

friend or someone with you.

HEARING REQUEST

I want a hearing due to an action by the Welfare Department

of ________________________________ County about my:

 Cash Aid  CalFresh (Food Stamps)  Medi-Cal

 Other (list)___________________________________________

Here's Why: ____________________________________________

_______________________________________________________



If you need more space, check here and add a page.

 I need the state to provide me with an interpreter at no cost to me.

(A relative or friend cannot interpret for you at the hearing.)

My language or dialect is: ____________________________

NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED

BIRTH DATE PHONE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

SIGNATURE DATE

NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER

 I want the person named below to represent me at this

hearing. I give my permission for this person to see my

records or go to the hearing for me. (This person can be

friend or relative but cannot interpret for you.)

NAME PHONE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

TEMP NA BACK 9 (TEMPORARILY REPLACES NA BACK 9, NA BACK 8 AND EP 5) (REVISED 9/2011) - REQUIRED FORM - NO SUBSTITUTE PERMITTED

YOUR HEARING RIGHTS

You have the right to ask for a hearing if you disagree with

any county action. You have only 90 days to ask for a

hearing. The 90 days started the day after the county gave or

mailed you this notice. If you have good cause as to why

you were not able to file for a hearing within the 90 days, you

may still file for a hearing. If you provide good cause, a

hearing may still be scheduled.

STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COUNTY OF

NOTICE OF ACTION -

DISCONTINUE

Notice Date :

Case

Name :

Number :

Worker

Name :

Number :

Telephone:

Address :

Questions? Ask your Worker.

(ADDRESSEE)

State Hearing: If you think this action is wrong, you can

ask for a hearing. The back of this page tells how. Your

benefits may not be changed if you ask for a hearing

before this action takes place.

Rules: These rules apply. You may review them at your county

welfare office: WIC 11253, AB 12 (Chapter 559, Statutes of 2010).

NA 1270 (11/11) DISCONTINUE NON-MINOR DEPENDENT - REQUIRED FORM - SUBSTITUTE PERMITTED

Page 1 of ____

As of _______________________, the County is stopping your cash

aid.

Here’s why:

■■ You no longer live with an approved relative.

■■ You no longer meet the age rules.

■■ You no longer meet one of the five eligibility conditions:

■■ Finishing high school or getting your GED.

■■ Enrolling in college or a vocational education program.

■■ Participating in a program or activity to help you find and keep

a job.

■■ Working at least 80 hours per month.

■■ Unable to do any of the above due to a verified medical

condition.

■■ You are no longer supervised by the juvenile court.

■■ You did not cooperate with the 6-month Review Hearings.

■■ You moved out of the State of California.

If you ask for a hearing before an action on Cash Aid,

Medi-Cal, CalFresh (Food Stamps), or Child Care takes place:

• Your Cash Aid or Medi-Cal will stay the same while you wait for a

hearing.

• Your Child Care Services may stay the same while you wait for a

hearing.

• Your CalFresh (Food Stamps) will stay the same until the hearing

or the end of your certification period, whichever is earlier.

If the hearing decision says we are right, you will owe us for any

extra Cash Aid, CalFresh (Food Stamps) or Child Care Services

you got. To let us lower or stop your benefits before the hearing,

check below:

Yes, lower or stop:

■■ Cash Aid ■■ CalFresh (Food Stamps)

■■ Child Care

While You Wait for a Hearing Decision for:

Welfare to Work:

You do not have to take part in the activities.

You may receive child care payments for employment and for

activities approved by the county before this notice.

If we told you your other supportive services payments will stop, you

will not get any more payments, even if you go to your activity.

If we told you we will pay your other supportive services, they will be

paid in the amount and in the way we told you in this notice.

• To get those supportive services, you must go to the activity the

county told you to attend.

• If the amount of supportive services the county pays while you

wait for a hearing decision is not enough to allow you to

participate, you can stop going to the activity.

OTHER INFORMATION

Medi-Cal Managed Care Plan Members: The action on this notice may stop

you from getting services from your managed care health plan. You may wish

to contact your health plan membership services if you have questions.

Child and/or Medical Support: The local child support agency will help

collect support at no cost even if you are not on cash aid. If they now collect

support for you, they will keep doing so unless you tell them in writing to stop.

They will send you current support money collected but will keep past due

money collected that is owed to the county.

Family Planning: Your welfare office will give you information when you ask

for it.

Hearing File: If you ask for a hearing, the State Hearing Division will set up a

file. You have the right to see this file before your hearing and to get a copy of

the county's written position on your case at least two days before the hearing.

The state may give your hearing file to the Welfare Department and the U.S.

Departments of Health and Human Services and Agriculture. (W&I Code

Sections 10850 and 10950.)

TO ASK FOR A HEARING:

• Fill out this page.

• Make a copy of the front and back of this page for your records.

If you ask, your worker will get you a copy of this page.

• Send or take this page to:

• Call toll free: 1-800-952-5253 or for hearing or speech impaired

who use TDD, 1-800-952-8349.

To Get Help: You can ask about your hearing rights or for a legal

aid referral at the toll-free state phone numbers listed above. You

may get free legal help at your local legal aid or welfare rights office.

If you do not want to go to the hearing alone, you can bring a

friend or someone with you.

HEARING REQUEST

I want a hearing due to an action by the Welfare Department

of ________________________________ County about my:

 Cash Aid  CalFresh (Food Stamps)  Medi-Cal

 Other (list)___________________________________________

Here's Why: ____________________________________________

_______________________________________________________



If you need more space, check here and add a page.

 I need the state to provide me with an interpreter at no cost to me.

(A relative or friend cannot interpret for you at the hearing.)

My language or dialect is: ____________________________

NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED

BIRTH DATE PHONE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

SIGNATURE DATE

NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER

 I want the person named below to represent me at this

hearing. I give my permission for this person to see my

records or go to the hearing for me. (This person can be

friend or relative but cannot interpret for you.)

NAME PHONE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

TEMP NA BACK 9 (TEMPORARILY REPLACES NA BACK 9, NA BACK 8 AND EP 5) (REVISED 9/2011) - REQUIRED FORM - NO SUBSTITUTE PERMITTED

YOUR HEARING RIGHTS

You have the right to ask for a hearing if you disagree with

any county action. You have only 90 days to ask for a

hearing. The 90 days started the day after the county gave or

mailed you this notice. If you have good cause as to why

you were not able to file for a hearing within the 90 days, you

may still file for a hearing. If you provide good cause, a

hearing may still be scheduled.

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Fill Online, Printable, Fillable, Blank Ab12 Acl 11 78 11 78.pdf (California State University, Fresno) Form

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Fillable Ab12 Acl 11 78 11 78.pdf (California State University, Fresno)

Fill Online, Printable, Fillable, Blank Ab12 Acl 11 78 11 78.pdf (California State University, Fresno) Form

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