STATE OF CALIFORNIA – HEATH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REFUGEE SERVICES –
DISTRIBUTION:
Original Copy: Service Provider
Second Copy:
Case File
INFORMATION TRANSMITTAL
SERVICE PROVIDER ADDRESS
RCA
CalWORKs
GA/GR
SSN
CLIENT NAME
CASE NUMBER
ALIEN NUMBER
WORKER NAME
DATE
WORKER NUMBER
TELEPHONE
(
)
REASON FOR COMMUNICATING (CHECK
AND/OR COMPLETE APPLICABLE ITEM)
SECTION I.
CLIENT STATUS CHANGES
Client continues as mandatory referral
Client no longer mandatory referral:
Exempt (Reason): __________________________________________________________________________________
Other (Reason): ____________________________________________________________________________________
Good cause was/was not found on ____________________ for the following reason: _____________________________________
(CIRCLE ONE)
_________________________________________________________________________________________________________
Sanction effective______________________________ through ______________________________________________________
SECTION II.
CHANGES TO CLIENT’S PERSONAL DATA
New address: ______________________________________________________________________________________________
_________________________________________________________________________________________________________
New telephone number: ____________________________________________________
Transfer to another aid program: _____________________________ to _______________________________________________
Social security number: _____________________________________________________
Client reported employment with _____________________________________________________________________________ at
NAME OF EMPLOYER
__________________________________________________________________________ on ____________________________ .
LOCATION
DATE
Client filed for State Hearing
State Hearing scheduled for____________________________ , at _______________________ , in _________________________.
(DATE)
(TIME)
(PLACE)
State Hearing outcome:
State Hearing request withdrawn
Client’s appeal granted
Client’s appeal denied
SECTION III.
COMMENTS
WORKER SIGNATURE
TELEPHONE NUMBER
DATE
(
)
RS 18 (5/03)