Form Rs 3 - Service Provider Referral/notification

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

RCA MANDATORY REFERRAL

CalWORKs MANDATORY REFERRAL

SERVICE PROVIDER

REFERRAL / NOTIFICATION FORM

ADDRESS OF COUNTY WELFARE DEPARTMENT

DISTRIBUTION:

Original Copy: Client

1st Copy

: Service Provider

2nd Copy

: Return to County Welfare Department When Notification is Required

TELEPHONE NO.:

(

)

----

3rd Copy

: County Welfare Department

COUNTY USE ONLY

1. CASE NAME

2. AU SIZE

11. YOU ARE REQUIRED TO REPORT TO THE SERVICE PROVIDER

3. AID CODE/CASE NUMBER

BEFORE YOU CAN BE ELIGIBLE FOR CASH ASSISTANCE.

4. REGISTRANT’S NAME

PLEASE TAKE THIS FORM TO THE FOLLOWING SERVICE

PROVIDER AND RETURN TO YOUR WORKER WITH DATED

ORIGINAL ON OR BEFORE _______________ .

5. SOCIAL SECURITY NUMBER

YOUR APPOINTMENT AT THE SERVICE PROVIDER IS

6. ALIEN NUMBER

SCHEDULED FOR:

A -

7. DATE OF ENTRY AS A REFUGEE, OR DATE GRANTED ASYLUM, OR DATE OF CERTIFICATION AS A

DATE:_________________ TIME:_________________

TRAFFICKING VICTIM

8. INTRACOUNTY OR INTERCOUNTY TRANSFER

FROM:

COUNTY/DISTRICT

12.

SERVICE PROVIDER ADDRESS

PREVIOUS SERVICE PROVIDER:

9. SPECIFY PRIMARY LANGUAGE DESIGNATED ON SAWS 1

10. DATE OF REFERRAL

TELEPHONE NO.: (

)

---

13. COMMENTS

14.

I certify that I have informed the applicant/recipient of his or her rights and responsibilities in regard to the RCA/ECA programs. I have explained

t h a t h e / s h e m u s t c o m p l y w i t h a l l e l i g i b i l i t y r e q u i r e m e n t s , s u c h a s r e p o r t i n g t o , a n d r e g i s t e r i n g w i t h t h e S e r v i c e P r o v i d e r ,

and participating and cooperating in training and employment activities, and that, if these requirements are not met, he/she may lose their grant.

DATE

WORKER’S SIGNATURE

WORKER’S NUMBER

SERVICE PROVIDER USE ONLY

15. Individual reported to Service Provider as required.

16. SERVICE PROVIDER EMBOSSING STAMP

AUTHORIZED SIGNATURE

DATE

When the above named registrant has completed participation in the training program or been

placed in employment, please complete the 1st and 2nd copies and return the 2nd copy to the

county welfare department addressed above.