CASE NO.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CalWORKs EXEMPTION REQUEST FORM
PLEASE PRINT
YOUR NAME
ADDRESS STREET
CITY
ZIP
PHONE
( )
QUESTIONS? ASK YOUR WORKER.
Most adults can only get 48 months (4 years) of cash aid from the CalWORKs program. Unless exempt, an
individual is required to participate in CalWORKs Welfare-to-Work activities as a condition for receiving aid.
INSTRUCTIONS TO THE CLIENT:
If you answer “Yes” to any of these questions, you may be exempt for a month or longer from the CalWORKs 48-month
time limit, Welfare-to-Work 24-Month Time Clock and/or participation requirements. You may need to give information to
help the county decide if you should be exempt. Please answer all of the questions. The county cannot answer these
questions for you. Please be sure to sign and date the back of this form.
YES NO Welfare-to-Work 24-Month Time Clock and Participation Exemptions
■ ■ 1. Are you pregnant and does a doctor state that you cannot work or participate in Welfare-to-Work
activities for:
• 20 hours per week if you are a single-adult assistance unit with a child under 6 years old.
• 30 hours per week if you are a single-adult assistance unit with no child(ren) under 6 years old.
• 35 hours per week if you are a two-parent assistance unit.
■ ■ 2. Are you the parent or caretaker of a child age ______ or under? (Depending on the County, you may
be exempt if your child is 12 weeks old or under, 6 months old or under, or 12 months old or under.)
This exemption is available only once in a lifetime.
■ ■ 3. If you have used exemption #2, have you recently become the parent or caretaker of another infant?
(Depending on the County, you may be exempt for 12 weeks to 6 months.)
■ ■ 4. Are you a full time volunteer in the Volunteers in Service to America (VISTA) Program?
YES NO CalWORKs 48-Month Time Limit, Welfare-to-Work 24-Month Time Clock and Participation
Exemptions
■ ■ 5. Are you a 16-or 17-year old who has a high school diploma or its equivalent and is enrolled or
planning to enroll in an educational, vocational or technical school training program?
■ ■ 6. Are you physically or mentally unable to work or participate in a Welfare-to-Work activity on a regular
basis for at least 30 calendar days for at least:
• 20 hours per week if you are a single-adult assistance unit with a child under 6 years old.
• 30 hours per week if you are a single-adult assistance unit with no child(ren) under 6 years old.
• 35 hours per week if you are a two-parent assistance unit.
■ ■ 7. Are you the nonparent caretaker of a child who is a dependent or ward of the court, or at risk of being
placed in foster care?
■ ■ 8. Do you need to stay home to take care of someone in the household who cannot take care of
him/herself, (the person is ill, disabled, etc.) and this makes it hard for you to work or participate in a
Welfare-to-Work activity?
■ ■ 9. Are you eligible for, participating in, or exempt from Cal-Learn? You are not eligible for this
exemption if you are 19 years old and are not participating in Cal-Learn as a volunteer.
■ ■ 10. Are you living in Indian Country, as defined by federal law, in which 50 percent of the adults are
unemployed? (This exemption applies only to the 48-month time limit, but not to the Welfare-to-Work
24-Month Time Clock or participation.)
■ ■ 11. Are you the parent or caretaker of a child age 0 - 23 months? This exemption is available only once
in a lifetime starting 1/1/2013. You can take it now if it applies or save it in case you have another child.
PLEASE READ THE BACK OF THIS FORM TO FIND OUT ABOUT MORE EXEMPTIONS.
CW 2186A (12/12) REQUIRED FORM - NO SUBSTITUTE PERMITTED
