Form Temp 2120 - Welfare To Work Referral

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
WELFARE TO WORK REFERRAL
ATTACHMENT
Completed by Welfare to Work Case Manager (WTWCM)
Welfare to Work Office No:
WTWCM No:
Participant Name:
Social Security Number:
CalWORKs Case #:
Address: (Street, City, Zip)
Mailing Address, if different:
Telephone number:
Sex:
Birthdate:
Citizen: Yes ( ) No ( ) IF NO,
M ( ) F ( )
Legal right to work in U.S.:Yes ( ) No ( )
Additional Comments:
I CERTIFY THAT THE ABOVE DATA HAS BEEN VERIFIED/DOCUMENTED BY AN EMPLOYEE OF THE COUNTY WELFARE
DEPARTMENT. THE DEPARTMENT CERTIFIES THAT THIS INDIVIDUAL HAS PROVIDED DOCUMENTATION THAT HE/SHE
IS LEGALLY ENTITLED TO WORK IN THE U.S.
Welfare to Work Case Manager Signature: ____________________________________________________________
Telephone Number: _____________________________ Date:____________________________________________
I AUTHORIZE THE EXCHANGE OF PERTINENT Welfare to Work/CalWORKs INFORMATION BETWEEN (WELFARE
DEPARTMENT), STATE OR FEDERAL AGENCIES OR THEIR REPRESENTATIVES FOR MONITORING, HEARINGS AND/OR
AUDITING PURPOSES.
________________________________
_____________
Welfare to Work Participant Signature
Date
TEMP 2120 (8/00) RECOMMENDED

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