Form Cw 215 Notification Of Intercounty Transfer
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTIFICATION OF INTERCOUNTY TRANSFER
Instructions: Workers should complete each space. If the information
requested does not pertain to this case, indicate with N/A symbol.
CASE NAME
CASE NUMBER
SENDING COUNTY NAME AND ADDRESS
RECIPIENT ADDRESS
NUMBER/STREET
CITY
ZIP CODE
RECEIVING COUNTY
RECIPIENT’S MAILING ADDRESS (IF DIFFERENT)
DISCONTINUANCE DATES FOR TRANSFER
RECIPIENT’S PHONE NUMBER(S)
DATE MOVED
CalWORKs
RCA
I
WAIVE 30 DAY ICT PROCESS:
PAYEE'S NAME (IF DIFFERENT)
SSN
WELFARE-TO-WORK PLAN
PAYEE’S RELATIONSHIP TO AIDED CHILD(REN)
DATE
NAME
I
SIGNED
I
REFUSED TO SIGN
I
I
APPEAL FILED TIMELY
YES
NO
SUMMARY OF INCOME/PROPERTY
I
SB 1041 RULES DATE
COMPLIANCE PLAN
BEGIN DATE ___________________________
MONTH
NAME
SOURCE
AMOUNT
END DATE _____________________________
WELFARE-TO- WORK COMPONENT
$
I
DATE
NAME
SIGNED
$
I
REFUSED TO SIGN
I
I
APPEAL FILED TIMELY
YES
NO
$
SB 1041 RULES DATE
I
COMPLIANCE PLAN
BEGIN DATE ___________________________
END DATE _____________________________
I
$
RESTRICTED ACCOUNT(S)
BALANCE
WELFARE-TO- WORK COMPONENT
TIME LIMITS
NAME:
NAME:
I
I
AB 98 or Expanded Subsidized Employment?
YES
NO
DATES: FROM ____________________ TO ____________________
NUMBER OF TANF MONTHS USED?
NUMBER OF TANF MONTHS USED?
OVERPAYMENTS TRANSFERRED
PROGRAM
TYPE
NUMBER OF CalWORKs MONTHS USED?
NUMBER OF CalWORKs MONTHS USED?
I
I
I
I
CalWORKs
IPV
Client-error
Agency
Mult.
24____
48____
24____
48____
CAL-LEARN CASE INFORMATION
I
I
I
I
Other (Specify)
IPV
Client/Provider
Agency
Mult.
I
I
I
NAME___________________
SANCTION
PENALTY
BONUS
SANCTIONS/PENALTIES
Check () all that apply for each person
I
I
I
NAME___________________
SANCTION
PENALTY
BONUS
Name
Start
End
MFG
Date
Date
I
NAME
_______________________________________________________________________
EXEMPT
I
I
I
I
I
CalWORKs IPV
6 mo
12 mo
2 yr
4 yr
Perm
I
NAME
_______________________________________________________________________
EXEMPT
I
I
I
NAME
_______________________________________________________________________
EXEMPT
School Attendance
Immunization
I
I
I
PRIOR NOTIFICATION DATE _____________________ FORM USED _____________
CS Sanction
CS 25% Penalty
CS Good Cause
I
Welfare-to-Work Sanction Cure Plan Contact Date________________________________
LATEST NOTIFICATION DATE
FORM USED
__________________________
_________________
Cure Plan Complete Date ______________________________
DOCUMENTATION SENT
I
I
RESTRICTED ACCOUNT
EXEMPTION (CW 2186B)
Name
Start
End
I
I
MFG EXEMPTION
SAWS 1/SAWS 2/SAWS 2A QR/
Date
Date
I
I
CW 2102
CW 25/
SAWS 2A SAR/SAWS 2 PLUS
QR 25A/CW 25A
I
I
I
I
I
I
TIME LIMIT NOTICE (COPY BOTH SIDES)
CalWORKs IPV
6 mo
12 mo
2 yr
4 yr
Perm
I
WTW PLAN
I
DISABILITY VERIFICATION
I
WTW 20
I
I
I
School Attendance
Immunization
PREGNANCY VERIFICATION
I
WTW 37
I
I
I
I
CS Sanction
CS 25% Penalty
CS Good Cause
OP RECORDS
I
WTW 24-MONTH TIME CLOCK
I
I
Welfare-to-Work Sanction Cure Plan Contact Date________________________________
QR 7/SAR 7
NOTICES
I
Cure Plan Complete Date ______________________________
PE DETERMINATION NAME
I
OTHER (LIST)
CASE INFORMATION
I
CalWORKs
I
RCA
COMMENTS:
PRIOR MONTH GRANT AMOUNT
CURRENT MONTH GRANT AMOUNT
$ _____________
$_____________
I
I
EXEMPT MAP
EXEMPT MAP
DATE RCA TIME EXPIRES
I
I
WORKER INFORMATION
HOMELESS ASSISTANCE RECEIVED?
YES
NO
_________________________
DATE_
WORKER NAME
WORKER NUMBER
PHONE HOURS
I
I
FOSTER CHILD(REN):
YES
NO
I
I
PHONE NUMBER
FAX
DATE COMPLETED
NON-MINOR DEPENDENT:
YES
NO
(
)
(
)
DATE OF LAST RECERTIFICATION:_
_________________________
CW 215 (4/14) REQUIRED FORM - SUBSTITUTE PERMITTED
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