Form Mc 325 - Request For Transitional Medi-Cal (Tmc) Or Four Month Continuing Medi-Cal

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Department of Health Care Services
State of California—Health and Human Services Agency
REQUEST FOR TRANSITIONAL MEDI-CAL (TMC) OR FOUR MONTH CONTINUING MEDI-CAL
Did your Medi-Cal or CalWORKS cash aid stop and:
You or your family has earnings from a job, self-employment, or a pay raise?
Yes
No
You or your family started receiving or had an increase in child/spousal support payments?
Yes
No
If you answered “YES” to either of these questions, you and other family members may still be eligible for Medi-Cal. Complete
the form and attach your and your spouse’s or other parent’s most recent pay stubs or other proof of earnings. If you are
self-employed, list business costs on a separate sheet of paper and attach proof of income and costs.
RETURN THIS REQUEST FORM TO YOUR COUNTY WORKER OR YOUR WELFARE OFFICE. DO NOT RETURN THIS
FORM TO THE DEPARTMENT OF HEALTH CARE SERVICES.
Please type or print clearly.
Name
TOTAL HOURS
MM
DD
YY
MM
DD
YY MM
DD
YY
MM
DD
YY
MM
DD
YY
WORKED IN
DATE PAID:
____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____
REPORT MONTH:
Employer/source
$
$
$
$
$
GROSS AMOUNT:
Name
TOTAL HOURS
MM
DD
YY
MM
DD
YY MM
DD
YY
MM
DD
YY
MM
DD
YY
WORKED IN
DATE PAID:
____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____
REPORT MONTH:
Employer/source
$
$
$
$
$
GROSS AMOUNT:
Name
TOTAL HOURS
MM
DD
YY
MM
DD
YY MM
DD
YY
MM
DD
YY
MM
DD
YY
WORKED IN
DATE PAID:
____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____
REPORT MONTH:
Employer/source
$
$
$
$
$
GROSS AMOUNT:
Did your family have any other changes, such as someone moved in or out of the house or was married, divorced, or became
pregnant?
Yes
No
If yes, please explain: _____________________________________________________
_______________________________________________________________________
I declare under penalty of perjury that all information provided is true and correct.
Name
Date of birth
Social security number
Signature
County case number
Telephone number
(
)
Address (number, street)
City
ZIP code
Signature of witness, interpreter, or person assisting
Date
Telephone number
(
)
MC 325 (05/07)

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