Form Temp 2209 - Notice Of Action
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2STATE OF CALIFORNIA
COUNTY OF
HEALTH AND HUMAN SERVICES AGENCY
NOTICE OF ACTION
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.
Based on our review of your CalWORKs Welfare-to-Work Activities
You are scheduled for a third party assessment on _________
Review Request Form and the information that you provided, the
______________________________ at ____________________
(DATE)
county is taking the following action(s):
o’clock at ____________________________________________
(ADDRESS)
Your request for a third party assessment has been denied.
This appointment is very important. If you cannot keep this
Here is why:
appointment, call ______________________________________
(WELFARE-TO-WORK WORKER)
(
)
County records show that you did not disagree with results of
at _________________________________ to schedule another
(PHONE)
your assessment.
date. If we are not available, please leave a message and we
will get back to you.
County records show that you disagreed with the results of
your assessment, but you and the county worked out the
problem.
Your request for a third party assessment has been approved.
Here is why:
County records show that when you disagreed with the results
of your assessment you were not sent to a third par ty
assessment.
You are approved for a third party assessment, and we
will send you a notice at a later date to tell you the date,
time, and place of your appointment.
Other_____________________________________________
_________________________________________________
_________________________________________________
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 42-711.556.
TEMP 2209 (4/02) CalWORKs WELFARE-TO-WORK ACTIVITIES THIRD PARTY ASSESSMENT NOTICE OF ACTION -REQUIRED – NO SUBSTITUTE PERMITTED
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