STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
WELFARE-TO-WORK (WTW) 24-MONTH TIME CLOCK EXTENSION REQUEST FORM
COUNTY USE ONLY
OTHER ID NO.
QUESTIONS? ASK YOUR WORKER.
Once you have used all 24 months of your WTW 24-Month Time Clock, you will have to meet different Welfare-to-Work rules to continue
getting your portion of cash aid and supportive services. However, you can get an extension of your WTW 24-Month Time Clock if you meet
one of the conditions listed below.
Please check the box that applies. Please be sure to sign your name and date this form. Along with this form, please give the county any
proof that you can provide to help the county decide if you can get an extension to the WTW 24-Month Time Clock and continue to
be in activities in your current welfare-to-work plan.
WTW 24-MONTH TIME CLOCK EXTENSIONS
1 Are you in an educational program, including adult basic education, vocational education, or a self-initiated
program, that you will be finishing soon?
If yes, what is your graduation, transfer, or completion date? ___________
2 Are y o u in a treatment program, such as a program for substance abuse or mental health, that you will b e
If yes, what is your completion date? _________________
3 Do you need more time to complete an activity in your welfare-to-work plan due to a learning disability or other
4 Have you submitted an application to receive Supplemental Security Income (SSI) disability benefits?
If yes, what is the date of your hearing? ______________
5 Are you in a two-parent assistance unit where the other parent has not yet used all of his or her WTW 24-Month
6 Are you likely to get a job in the next six months? Please explain below.
7 Has there been a change in the job market that has temporarily prevented you from getting a job so you need
more time to get one? Please explain below.
PLEASE CONTACT YOUR WORKER IF YOU HAVE QUESTIONS ABOUT THIS FORM.
If you need help getting proof of your condition, your worker can help you.
You will get a notice if you do or do not get an extension to the WTW 24-Month Time Clock and the reason why.
If you do not agree with the county, you may ask for a state hearing.
If you think you should not be in Welfare to Work and have not asked for an exemption, or need more information about exemptions
from participation in Welfare to Work , please contact your worker.
WTW 44 (1/15) REQUIRED FORM – NO SUBSTITUTE PERMITTED