GN 6070 (05/13)
PROGRESS REPORT - EDUCATION/TRAINING/POST-EMPLOYMENT SERVICES/
WORK EXPERIENCE AND COMMUNITY SERVICES PROGRAM
Participant Name/Address
GAIN Regional Office Address:
Fax Number:
GSW Name: Phone Number:
(Service Type & Activity Number Program Description)
GSW ID:
Agency/School Name:
Case Number: Date:
Report Period From: To:
Report Due:
This progress report is a required document that needs to be completed and turned in timely. Failure to provide this
form by the due date may affect your cash aid. If you have any questions, please contact your GAIN Services
Worker.
Please forward this form to your agency or school's CalWORKs office for completion. Email, mail, fax or walk-in this
completed form to your GAIN Services Worker by the due date indicated above.
SECTION A: TO BE COMPLETED BY YOUR AGENCY or SCHOOL
Making Satisfactory Progress
in Overall Program:
Yes
No
If no, explain:
Print Name of Agency/School Official
Completing Form:
Title of Agency/School Official
Completing Form:
Telephone Number:
Email:
Fax Number:
Official Agency/School Stamp:
Meeting Attendance Standard:
Yes No
Signature of Agency/School Official Completing Form: Date:
SECTION B: TO BE COMPLETED BY THE PARTICIPANT
• If your school does not have a CalWORKs Office available, attach your recent transcript or report card to this
progress report and submit to your GAIN Services Worker by the due date indicated above.
• If your service provider is unable to complete this form and you do not have your recent transcripts or report
card, call your GAIN Services Worker to make an appointment to complete an affidavit of temporary
declaration.
I understand that any deliberate misrepresentation of the above information may result in a penalty which can reduce the
amount of my aid or cause me to become ineligible for cash aid. I also authorize the release of the above information to the
County of Los Angeles, Department of Public Social Services by the service provider.
Participant Signature:
Telephone Number: Date:
File: GPRF: Permanent
DEPARTMENT OF PUBLIC SOCIAL SERVICES
