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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CARETAKER RELATIVE AGREEMENT
COUNTY OF
The County will use this agreement to decide which adult can get cash aid with the children. This agreement is not meant to
change any other custody agreement you have for the children.
We understand that only one Caretaker Relative can get cash aid along with the children.
We agree that is the person who provides the care and control and is the
Caretaker Relative for the following children:
NAME
/
DATE OF BIRTH NAME
/
DATE OF BIRTH
NAME
/
DA
TE OF BIRTH NAME
/
DA
TE OF BIRTH
NAME
/
DA
TE OF BIRTH NAME
/
DA
TE OF BIRTH
SIGNATURE OR MARK OF APPLICANT DA
TE PRINT NAME IN FULL
SIGNATURE OR MARK OF APPLICANT DAT
E PRINT NAME IN FULL
SIGNATURE OF WITNESS TO MARK(S)
COUNTY USE ONLY
CASE NUMBER
CASE NAME
CASE NUMBER
CASE NAME
This agreement is to be used only when a caretaker relative is to be chosen under MPP 82-808.413(c).
CW 13 (9/02) REQUIRED FORM - NO SUBSTITUTE PERMITTED
