Form Temp 2212 - Notice Of Action
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2STATE OF CALIFORNIA
COUNTY OF
NOTICE OF ACTION
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date :
Case
Name
:
Number
:
Worker
Name
:
Number
:
Telephone :
Address :
(ADDRESSEE)
Questions? Ask your Worker.
State Hearing: If you think this action is wrong, you can
ask for a hearing. The back of this page tells you how.
SUPPORTIVE SERVICES
Your payment:
A check(s) to cover back supportive services costs due to you
CHILD CARE
will be sent soon.
Your back child care costs from ___________________
A check(s) is enclosed for back supportive services due to
through ______________________ have been approved for
you.
the amount of $ ______________. The attached sheet shows
how we computed your child care costs.
Other : ___________________________________________
Other:____________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
TRANSPORTATION
Your transportation costs from _____________________
If you have any questions about this form, call your worker:
through _______________________ have been approved for
the amount of $ ____________. The attached sheet shows
_____________________________________________________
how we computed your transportation costs.
(WORKER’S NAME)
Other:____________________________________________
at (
) ______________________________.
_________________________________________________
(PHONE)
_________________________________________________
_________________________________________________
ANCILLARY
As of ____________________________ the county has
(DATE)
approved your request for payment for the following items
needed for your approved welfare-to-work activity:
Item
Amount
_______________________________
$ _________________
_______________________________
$ _________________
_______________________________
$ _________________
Medi-Cal: This Notice of Action does NOT change or stop
Medi-Cal benefits. Keep your plastic Benefits Identification
_______________________________
$ _________________
Card(s).
_______________________________
$ _________________
Rules: These rules apply. You may review them at your welfare
office: MPP 42-750.
TEMP 2212 (5/02) CalWORKs WELFARE-TO-WORK ACTIVITIES REVIEW FOR SUPPORTIVE SERVICES APPROVAL FORM - REQUIRED – NO SUBSTITUTE PERMITTED
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