Fillable CalWORKs Program Aid Verification Form (Folsom Lake College)

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CalWORKs Program Aid Verification Form (Folsom Lake College)

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CalWORKs Program Aid Verification Form
Thank you for your consideration and time in completing this document for our common student.
Please contact the respective CalWORKs office if you have any questions regarding this request.
☐American River College
☐Sacramento City College
☐Folsom Lake College
☐Sacramento City College
SECTION 1 – STUDENT INFORMATION (to be completed by the student)
Last Name, First Name:
Student ID #:
Last 4 of Social Security #:
The information requested below is specifically for the current time period.
SECTION 2 – STUDENT CASE ELIGIBILTIY (Must be completed by respective county representative.)
1. Is the student a current recipient of cash aid via the county’s
CalWORKs program?
☐
Yes
☐
No Date Services Started: __/___/___
2. Is this school an approved Welfare-to-
Work activity for this student?
☐
Yes
☐
No
3. a) What are the total number of dependent children on the
student’s case who are currently receiving cash aid?
_____________________________________________
b) Does the student have at least one dependent child who is 13 years old or younger? ☐
Yes
☐
No
4. Is the student defined as single, head of household?
☐
Yes
☐
No
5. Student’s current legal marital status:
☐
Married
☐
Single
☐
Divorced
☐
Separated
6. a) What is the student’s curren t CalWORKs eligibility status?
☐Aided ☐Sanctioned ☐Timed Out (Date: __/___/___) ☐Discontinued from Aid (Date: __/___/___) ☐Other
If the student is currently in sanction status is education approved to cure their sanction?
☐
Yes
☐
No
b) If “Aided” or “Other,” please select the most appropriate status below (please see reverse side for standard
definitions of these terms):
☐County Referred ☐Self-Initia
ted (SIP) ☐Voluntary Exempt ☐Exempt (other) ☐Post-Employment
7. Are there any other adults on the case that are eligible for
CalWORKs services (spouse, partner, etc.)?
☐
Yes
☐
No
8. If the student completes the process, is the student eligible to receive childcare through the county?
☐
Yes
☐
No
9. If the student submits all school verification for the current semester, will the county cover costs for the following:
Text books:
☐
Yes
☐
No Supplies:
☐
Yes
☐
No Transportation:
☐
Yes
☐
No Other ___________:
☐
Yes
☐
No
10. a) Please indicate if the student is utilizing the CalWORKs Minimum Standards or CalWORKs Federal Standards, and
how many month(s) are remaining on the CalWORKs 48-Month Time Clock.
☐CW Minimum Standards ☐CW Federal Standards Months Remaining: ___________
b) What is the student’s/family’s WTW participation hours requirement?_______________
If the answer is NO to questions 1, 2, & 6 (not aided or sanctioned), no CalWORKs services can be rendered.
Name of Agency:
Student County Case Number:
Agency Representative/Worker Name:
Agency Representative Telephone:
Agency Representative/Worker Signature
Date:
/ /
(Not valid without signature and county stamp.)
Not valid for Fall semester
if dated before August 1st.
American River College
Ph: 916-484-8059
Fax: 916-484-8573 Attn:
ARC CalWORKs
Sacramento City College
Ph: 916-558-2331
Fax: 916-558-2169 Attn: SCC CalWORKs
Cosumnes River College
Ph: 916-691-7465
Fax: 916-691-7434 Attn: CRC CalWORKs
Folsom Lake College
Spring 2019
El Dorado Center
Ph: 530-642-5620
Fax: 916-608-6637 Attn: CalWORKs
Folsom Main Campus
Ph: 916-608-6560
Fax: 916-608-6637 Attn: CalWORKs
Rancho Cordova Center
Ph: 916-361-6305
Fax: 916-608-6637 Attn: CalWORKs
xxx-xx-_________
Must be stamped by
county to be valid.
Spring 2019
COUNTY STAMP HERE
✔
CalWORKs Program Aid Verification Form
☐
American River College
☐ Cosumnes River College
☐ Folsom Lake College
☐ Sacramento City College
Guidelines for CalWORKs Eligibility Verification Form Completion
1. No CalWORKs services can be provided without a current CalWORKs Eligibility Verification form on file.
2. This form must be completed each semester by all CalWORKs students (one form per student).
3. This form must be signed and stamped in the same month for which services are sought – services cannot be
provided retroactively.
4. Please make sure questions 1-10 are answered as complete as possible by your county worker/representative
before turning in this document – NO INCOMPLETE DOCUMENTS WILL BE ACCEPTED.
5. All documents require both a county worker/representative signature and county stamp/seal to be valid.
Receipt of this document by the CalWORKs office does not guarantee that services or support will be provided, as all
services and support are provided per funding and the director’s discretion.
CalWORKs Student Eligibility Definitions
County Referred Participant:
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child and was referred
to the community college by the county welfare office and has an approved Welfare-to-Work (WTW) plan or is in the
process of developing a WTW plan.
Self-Initiated Participant (SIP):
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child and is attending
the community college as a Self-Initiated Participant (SIP) and is or will be in the process of obtaining an approved
WTW plan through their county welfare office. Refer to the California Department of Social Services All County Letter
99-32 for additional information on SIP criteria.
Voluntary Exempt:
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child but has been
exempted from participating in WTW activities by the county for a reason enumerated with an All County Letter or All
County Information Notice.
Exempt Student (other):
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child but has been
exempted from participating in WTW activities. The college must have documentation in the student’s file proving the
student’s exempt status and when the exemption will expire.
Post-Employment Participant:
This designation applies if the student is off cash assistance due to unsubsidized employment and is in compliance
with their county welfare office. This would be a former CALWORKs/cash aid recipient who has completed their WTW
plan or SIP and is employed but desires additional training. A student in this status cannot be one that is sanctioned by
the county welfare office for not adhering to their WTW plan. The college must verify student employment at the
beginning of each term.
If your student/customer does not fall into County Referred or SIP categories, please detail the student’s situation per
Question 6b on the reverse side of this document or contact the respective CalWORKs office at the numbers provided.
✔
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CalWORKs Program Aid Verification Form (Folsom Lake College)

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Completed 4 September 2020

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