STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STUDENT FINANCIAL AID STATEMENT
WELFARE-TO-WORK SUPPORTIVE SERVICES
Welfare-to-Work pays for items you need to do your
assigned Welfare-to-Work activities or to work. These
supportive services are child care, transportation, ancillary
expenses (such as tools, uniforms, books or school supplies)
and personal counseling. If necessary supportive services
are not available, you will have good cause for not
participating.
I understand that I do not have to use any part of my
student financial aid (student grant, loan or work/study
grants) to pay for the supportive services that I can get
from Welfare-to-Work.
I understand that I may choose to use some or all of my
student financial aid to pay for the supportive services that I
can get from CalWORKs while I am in Welfare-to-Work.
I understand that if I agree to use some or all of my student
financial aid for my supportive services:
• I can change my mind at any time and stop using these
funds for my supportive services.
• If I change my mind, the county will again pay for my
supportive services. I must complete Part B of this form.
• If I change my mind, the county will not pay for the
expenses I agreed to pay for before I told the county I
changed my mind.
COUNTY
CASE NAME
PARTICIPANT'S NAME
WORKER’S NAME
WTW 8 (6/04) REQUIRED FORM - SUBSTITUTES PERMITTED
PART A: VOLUNTARY USE OF FINANCIAL AID FUNDS FOR SUPPORTIVE SERVICES THAT CAN BE PAID FOR BY
CalWORKs
■■ NO. I do not want to use my financial aid to pay for supportive services.
■■ YES. I voluntarily agree to use my financial aid to pay for supportive services, as follows:
■■ Child Care $ ___________ per _____________ beginning _____________ and ending_____________
■■ Transportation $ ___________ per _____________ beginning _____________ and ending ____________
■■ Ancillary $ ___________ per _____________ beginning _____________ and ending ____________
■■ Personal $ ___________ per _____________ beginning _____________ and ending ____________
Counseling
I CERTIFY THAT I UNDERSTAND THIS FORM AND THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.
Participant’s Signature: __________________________________________________________ Date: ________________
I CERTIFY THAT I INFORMED THE PARTICIPANT THAT USE OF FINANCIAL AID TO PAY FOR SUPPORTIVE
SERVICES THAT CAN BE PAID FOR BY CalWORKs IS VOLUNTARY AND I HAVE PROVIDED A COPY OF THE
COMPLETED FORM TO THE PARTICIPANT.
Signature of county worker receiving Part A: __________________________________________ Date: ________________
PART B: ENDING VOLUNTARY USE OF FINANCIAL AID FOR SUPPORTIVE SERVICES
■■ STOP. I no longer want to use my student financial aid to pay for supportive services.
I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.
Participant’s Signature: ___________________________________________________________ Date: _______________
The county received Part B on _____________________. You will get a notice telling you what supportive services the
county can pay for. You also will receive a copy of this form when it is completed.
Signature of county worker receiving Part B: ___________________________________________ Date: _______________
ORIGINAL COPY TO CASE FILE - COPY TO PARTICIPANT
