Form Soc 822 - Cash Assistance Program For Immigrants (Capi) - Notification Of Inter-County Transfer

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DEPARTMENT OF SOCIAL SERVICES - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
NOTIFICATION OF INTER-COUNTY TRANSFER
To: (Receiving County/Consortium)
Date:
Transferring County/Consortium and Address:
Case Name:
SSN:
Sending Case No.:
Spouse Name:
Date Moved/Date Notified:
SSN:
Sending Case No.:
CAPI Discontinuance Date:
Participant’s New Residence Address:
Prior Living Arrangement:
Independent
Shared
Participant’s Mailing Address (if different)
Living with Adult Child
Other
Current Living Arrangement (after move), if known:
Participant’s Phone Number:
Independent
Shared
Contact Person (if Different)
Living with Adult Child
Other
Relationship to Participant:
Phone:
DOCUMENTATION SENT
OVERPAYMENT INFORMATION
Balance Owed
Adjustment
SAWS 1
DAPD Verification
$
$
IAR (SOC 451)
Copy of whole file
Latest Statement of Facts
Sponsorship Verification
Redetermination Form
Noncitizen status verification
State IAR (SOC 455)
Other
OTHER INCOME
Source
Amount
Name
$
$
Worker #
Phone Number
Transferring Worker Name
Fax Number
Receiving Worker Name
Worker #
Phone Number
Fax Number
Transfer Accepted
Transfer Rejected: Reason:_________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SOC 822 (1/06)

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