Form Qr 25a - Payee Agreement For Minor Parent
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY USE ONLY
PAYEE AGREEMENT FOR MINOR PARENT
CASE NAME:
CASE NUMBER:
WORKER NAME:
If you do not return this form by_______________
you will not get cash aid.
SECTION A: PREGNANT OR PARENTING MINOR AGREEMENT
SECTION A: PREGNANT OR PARENTING MINOR AGREEMENT
I understand that any cash aid I am eligible to get for myself or dependent child(ren) will be paid to my parent, legal guardian, or
other adult relative, with whom I live. I give permission to give this agreement to the person named below.
NAME OF PROPOSED PAYEE
RELATIONSHIP
NAME OF MINOR
SIGNATURE OF MINOR
DATE
SECTION B:
SECTION B:
PAYEE RESPONSIBILITIES
PAYEE RESPONSIBILITIES
The above-named minor has applied for California Work Opportunity and Responsibility to Kids (CalWORKs) for him/herself and/or
his/her dependent child(ren). The minor has named you to serve as payee and receive cash aid payments. Payee responsibilities
are listed below:
•
I understand the payments I get for the person(s) in this case are to be used for their support. If I willfully and
knowingly receive or use any part of the payment for any reason other than to support them, state law says I may be
prosecuted for committing a misdemeanor.
•
I understand that I am responsible to make sure the minor is given all information sent to me by the county for the minor
such as quarterly report forms, notices of action and informing notices. It is the minor’s responsibility to complete any
necessary forms by the due date.
•
I understand that if the minor moves out of my home, I should notify the county within 5 days and any payments received
after the minor moves out should be returned to the county.
•
I understand that if I do not agree to become the payee it does not affect the eligibility of the minor and/or his/her
dependent child(ren).
SECTION C: PAYEE CERTIFICATION
SECTION C: PAYEE CERTIFICATION
Please check (✔) one of the boxes below:
■ ■
I understand the above facts and agree to act as the payee for the minor listed above.
■ ■
I refuse to act as the payee for the minor listed above.
PROPOSED PAYEE
PHONE NUMBER
DATE
QR 25A (5/04) REQUIRED FORM - SUBSTITUTES PERMITTED
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