Form Wtw 27 - Request For Good Cause Determination
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR GOOD CAUSE DETERMINATION
CLIENT’S NAME
CASE #:
DATE:
WELFARE TO WORK WORKER’S NAME
WORKER #:
PHONE #:
(
)
Returning this form is optional. You can still claim that you had a good reason (“good cause”) for not meeting Welfare to Work rules if you
do not return this form. Even if you do return this form, you must still call your Welfare to Work worker before your appointment OR go to the
appointment to talk about your Welfare to Work participation problem. If you do not go to your appointment or call, your cash aid may be
lowered if you do not give us enough information on this form to show us you had a good reason for not participating. The date, time, and
place of your appointment are on the Notice of Action (NA 840) that the county sent to tell you about your participation problem.
Instructions: If you had a good reason for not doing what you were supposed to do in Welfare to Work, fill out this form. Give us any
information you may have (for example, a doctor’s note) to show us that you had a good reason. You can also tell us about your good reason
by giving us the details in the section below.
After you fill out the form:
1)
Make a copy of the form for you to keep; AND
2)
Mail or take the form back to your Welfare to Work worker before the date of your appointment to discuss your participation
problem; OR bring the completed form to the appointment.
If you have any questions, call your Welfare to Work worker.
_________________________, our records show that you did not:
Good Cause Reasons:
Check all the reasons that apply to you. If your reasons are not on
the list, you can check the last box and write in your reason.
Sign the Welfare to Work plan on ______________________ .
I was sick.
Participate in ________________ on ___________________ .
My child or another member of my household was sick and
Make good progress in your _____________________ activity
needed my care.
I did not have child care.
because _________________________________________ .
I recently had a death in my family (spouse, parent, child, or
Accept a job at ____________________________________ .
close relative).
I did not have transportation or money for gas.
Keep your job at ___________________________________ .
The round trip travel time would be more than:
Keep the same amount of earnings.
two hours by bus or other public transportation
two miles round trip on foot
Weather or other act of nature prevented travel.
Your cash aid will not be lowered if you had a good reason for not
doing what we asked. Examples of good reasons are listed to the
I need help with a learning disability, mental health impairment,
domestic violence issue, or substance abuse problem.
right.
I am homeless or living in unstable, temporary housing.
I had legal problems.
You may have to give your worker more information to prove your
I was in jail.
reason.
I was working that day.
I never got a written notice.
If you do not have a good reason, your cash aid will not be lowered
I have language problems.
if you agree to a compliance plan and do what the plan says.
Any other reason that you believe should be considered.
(Explain:) ___________________________________________
___________________________________________________
___________________________________________________
Give us any details or information that will show us that you
CLIENT’S NAME (PLEASE PRINT)
had a good reason for not participating.___________________
______________________________________________________
CLIENT’S SIGNATURE
______________________________________________________
______________________________________________________
CLIENT’S PHONE NUMBER
DATE
______________________________________________________
WTW 27 (10/03) REQUIRED FORM - SUBSTITUTE PERMITTED
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