Original:Folder:Rev2013 Yellow:Student
Merced College-EOPS/CARE Program
CalWORKs Status Verification
The individual below has applied for services through Merced College – EOPS/CARE Program. In order
to determine eligibility for services the Program needs to have specific information on the client/student.
Release of Confidentiality
________________________________ ______________ __________________
Client/Student Name (Type or Print) Student ID # Cal WORKs Case #
I authorize the Department of Social Services to release the information requested on this form to Merced
College-EOPS/CARE Program. I also give permission to discuss necessary details relative to my case.
________________________________ ______________________
Signature Date
Certification of CalWORKs
Benefits Began (Month/Year) __________ Aid Code__________
Does the client have an active CalWORKs case number for the family? Yes No
Does the client receive cash aid benefits from CalWORKs or Tribal TANF? Yes No
If not, specify reason: (Sanctioned, Timed-Out, Incomplete Paperwork, _____________)
If client doesn’t receive cash aid, do the dependents receive cash aid? Yes No
Does the client have a current Welfare to Work Plan (WTW 2 Form) on
file with the local HHSA County Office? Yes No
Certification as Head-of-Household
Is the client currently classified as Single Head-Of –Household
(one parent assistance unit) by the Department of Social Services? Yes No
________________________________ _______________________
Agency Representative (type or print) Title/Official Position
________________________________ _______________________
Signature Date
( ) ________________________
Telephone Number
NOTE: FORM WILL NOT BE ACCEPTED WITHOUT REPRESENTATIVE’S SIGNATURE AND
AGENCY STAMP.
EOPS/CARE Program Stop 10
In collaboration with CalWORKs Program
Merced College, 3600 M St., Merced, CA 95348
Telephone Number (209) 381-6596; Fax (209) 384-6079;
Los Banos Campus Stop 53, 22240 Hwy. 152; Los Banos, CA 93635
Telephone Number (209) 381-6435; Fax (209) 381-6583
TO BE COMPLETED BY THE AGENCY PROVIDING BENEFITS
AGENCY STAMP
REQUIRED
