Form Wtw 8 - Student Financial Aid Statement Welfare-To-Work Supportive Services
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1STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY
STUDENT FINANCIAL AID STATEMENT
WELFARE-TO-WORK SUPPORTIVE SERVICES
CASE NAME
PARTICIPANT'S NAME
WORKER’S NAME
Welfare-to-Work pays for items you need to do your
I understand that if I agree to use some or all of my student
assigned Welfare-to-Work activities or to work. These
financial aid for my supportive services:
supportive services are child care, transportation, ancillary
expenses (such as tools, uniforms, books or school supplies)
•
I can change my mind at any time and stop using these
and personal counseling. If necessary supportive services
funds for my supportive services.
are not available, you will have good cause for not
participating.
•
If I change my mind, the county will again pay for my
I understand that I do not have to use any part of my
supportive services. I must complete Part B of this form.
student financial aid (student grant, loan or work/study
grants) to pay for the supportive services that I can get
•
If I change my mind, the county will not pay for the
from Welfare-to-Work.
expenses I agreed to pay for before I told the county I
I understand that I may choose to use some or all of my
changed my mind.
student financial aid to pay for the supportive services that I
can get from CalWORKs while I am in Welfare-to-Work.
PART A: VOLUNTARY USE OF FINANCIAL AID FUNDS FOR SUPPORTIVE SERVICES THAT CAN BE PAID FOR BY
CalWORKs
NO. I do not want to use my financial aid to pay for supportive services.
YES. I voluntarily agree to use my financial aid to pay for supportive services, as follows:
Child Care
$ ___________ per _____________ beginning _____________ and ending_____________
Transportation $ ___________ per _____________ beginning _____________ and ending ____________
Ancillary
$ ___________ per _____________ beginning _____________ and ending ____________
Personal
$ ___________ per _____________ beginning _____________ and ending ____________
Counseling
I CERTIFY THAT I UNDERSTAND THIS FORM AND THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.
Participant’s Signature: __________________________________________________________ Date: ________________
I CERTIFY THAT I INFORMED THE PARTICIPANT THAT USE OF FINANCIAL AID TO PAY FOR SUPPORTIVE
SERVICES THAT CAN BE PAID FOR BY CalWORKs IS VOLUNTARY AND I HAVE PROVIDED A COPY OF THE
COMPLETED FORM TO THE PARTICIPANT.
Signature of county worker receiving Part A: __________________________________________ Date: ________________
PART B: ENDING VOLUNTARY USE OF FINANCIAL AID FOR SUPPORTIVE SERVICES
STOP. I no longer want to use my student financial aid to pay for supportive services.
I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE AND CORRECT.
Participant’s Signature: ___________________________________________________________ Date: _______________
The county received Part B on _____________________. You will get a notice telling you what supportive services the
county can pay for. You also will receive a copy of this form when it is completed.
Signature of county worker receiving Part B: ___________________________________________ Date: _______________
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WTW 8 (6/04) REQUIRED FORM - SUBSTITUTES PERMITTED
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