Form Wtw 12 - Welfare To Work/cal-Learn Supportive Service Repayment Agreement
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NUMBER
WELFARE TO WORK/CAL-LEARN SUPPORTIVE SERVICE
CASE NAME
REPAYMENT AGREEMENT
ADDRESSEE
WORKER
DATE
I.
REPAYMENT TERMS AND CONDITIONS
You must repay what you owe by using one or more of the methods listed in Section III. Your total overpayment is $
■ ■
■ ■
for
for transportation or work/training related expenses,
education related expenses
You do not have to begin to repay the overpayment while you are in Welfare to Work/Cal-Learn if you would not be able to keep the child
care you have now or you would not have enough money to pay for child care, transportation, and/or education related expenses
work/training related expenses, that you need to be in Welfare to Work.
If you cannot repay or begin to repay now, tell your worker/case manager now or if this form was mailed to you, call your worker/case
manager within ten days of the date the form was mailed. If the County agrees, you will still have to pay back what you owe, just not
now. The County will then check to see if you can begin to repay when you change Welfare to Work/Cal-Learn activities.
If you have any questions, please call us at___________________________.
If this agreement has been mailed to you and you have no questions, complete and sign this agreement. Keep the last copy. Return all
other copies to the County. Do not send cash with this agreement. If you pay by cash, pay in person. Be sure to ask for a numbered
receipt with the County name on it.
When approved by the County, a signed copy of this agreement will be sent to you.
If you are still in Welfare to Work/Cal-Learn and do not return this agreement, completed and signed within ten days of the date this
notice was mailed to you, the County will take action to collect the overpayment by reducing your next payment.
If you are no longer in Welfare to Work/Cal-Learn and you do not return this form within ten days of the date this notice was mailed to
you the County will demand payment and take other action to collect the overpayment.
II.
I understand that:
1.
Any changes in my ability to pay can change my monthly payments.
2.
If anything changes, I can ask the County to enter into a new repayment agreement with me.
3.
If I do not pay as agreed; no longer get cash Aid; or for any reason this agreement no longer works, the County will require a new
repayment agreement.
4.
If I do not pay back the County as I have agreed, they can sue me to recover the amount owed even if it is beyond three-years.
I may have to pay collection costs, attorney fees, court costs, and interest.
5.
If I do not pay, the County may take my state income tax refund and/or ask for the court to attach my wages or any property I own.
6.
The County may ask other family members to repay if I do not repay the overpayments.
Put your initials here _____ to show
III. Check below the ways you want to repay. Fill in the amount(s) you will repay.
that you have read and understand
1.
Cash Payment
items 1 through 6 above.
You may repay all or part of what you owe with cash.
■ ■
I will repay by lump sum cash payment of $ _______________ by _____________
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I will repay by monthly cash payment of $ _________________ by the first day of each month beginning ________________.
2.
Payment Reduction
If you get Welfare to Work/Cal-Learn supportive services payments, you can repay by a percentage of your monthly payment or you
can pay more if you want to. The highest amount you have to repay is 10% of your supportive services monthly payment, if the
overpayment was caused by you. If the overpayment was an error by the County, the highest amount you have to repay is 5% of
your monthly supportive services payment. You can choose to pay the same amount each month.
■ ■
I will repay the highest amount that applies in my case.
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Instead of the highest amount, I will repay by having my supportive services payment reduced by $ ____________________
each month.
3.
Grant Reduction
You may repay by having your cash aid payment reduced.
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I will repay by having my cash aid grant reduced by $ ________each month.
IV. CHECK THE BOX BELOW THAT APPLIES TO YOU
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I can begin repayment within 30 days from the date this notice was mailed to me.
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I cannot begin to repay within 30 days from the date this notice was mailed to me, but I will begin to repay in the way(s) I chose in
Section III, by_________________________.
Mail this form and payments to:
Bring this form and payments "in person" to:
Sign your name below and enter the date.
Signature ______________________________________________ Date ____________
V.
To be completed by the County
The above signed Agreement has been accepted by ________________________________________ on _________________
for
__________________________________________________ County.
Signature ______________________________________________
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