Form Temp Na 2206 - Notice Of Action
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2NOTICE OF ACTION
STATE OF CALIFORNIA
COUNTY OF
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.
Your benefits may not be changed if you ask for a
hearing before this action takes place.
You asked that your CalWORKs welfare-to-work activity
Your third-party assessment shows that your welfare-to-work
assignment be reviewed for the following reason(s):
plan was correct.
_________________________________________________
You were not sanctioned.
_________________________________________________
You were sanctioned, but not because you disagreed with one
_________________________________________________
or more of the situations listed below:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Based on our review of your CalWORKs Welfare-To-Work Activities
Review Request Form and the information that you provided, your
_________________________________________________
request has been denied. Here’s why:
_________________________________________________
Your CalWORKs Welfare-to-Work Activities Review Request
_________________________________________________
Form was received after July 1, 2002.
_________________________________________________
You did not give us the additional information/documentation
Your request has been forwarded to ____________________
regarding _________________________________________
________________________ County. That county will be
_________________________________________________
contacting you on the decision on your claim.
that we asked for on ________________________________ .
(DATE)
The county did not limit you to less than 18/24 months of
vocational training, adult basic education, General
Equivalency Diploma (GED), English-as-a Second Language
(ESL), or other educational program.
The county limited you to less than 18/24 months of vocational
training, adult basic eduction, General Equivalency Diploma
(GED), English-as-a Second Language (ESL), or other
educational program, but did so based on your individual
assessment and not as a matter of general policy.
The county did not send you to an education or training
program, but it was based on your individual assessment, and
Medi-Cal: This Notice of Action does NOT change or stop
not a general policy requiring that you only get education if
Medi-Cal benefits. Keep your plastic Benefits Identification
you were working part-time or if you already had a high school
Card(s).
diploma or GED.
The county did not make everyone attend work experience as
Rules: These rules apply. You may review them at your welfare
their first activity after signing their welfare-to-work plan.
office: MPP 42-710, 42-711, & 42-716.
TEMP 2206 (4/02) CalWORKs WELFARE-TO-WORK ACTIVITIES REVIEW REQUEST DENIAL FORM -REQUIRED – NO SUBSTITUTE PERMITTED
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