Form Cw 2190b - Calworks 48-Month Time Limit Extender Determination Form
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY
CASE NAME
CalWORKs 48-MONTH TIME LIMIT
EXTENDER DETERMINATION FORM
OTHER ID NO.
CASE NO.
WORKER NAME
Questions? Ask your worker.
Date____________________
On _________________________, a 48-month time limit extender was requested for______________________________________ .
(DATE)
(NAME)
Based on the facts in your case, the county made the following decision.
1.
The 48-month time limit extender is APPROVED. The county has found that you meet the rules to qualify for a time limit
extender at this time. If you are currently getting cash aid, you will not be discontinued due to time limits. If you are not currently
getting cash aid, you will receive a separate notice regarding your eligibility and any changes to your grant amount.
Starting on ___________________, your CalWORKs 48-month time limit will be extended and you will continue to get cash aid.
Your extender will end on ____________________.
Notify the county if the condition extending your CalWORKs 48-month time limit changes.
Reason for Approval:__________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2.
The 48-month time limit extender is DENIED. You do not meet the rules to qualify for a time limit extender at this time and will
not be aided. If your condition changes, call your worker to ask for a time limit extender.
Reason for Denial:____________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CONTACT YOUR WORKER IF YOU THINK THIS NOTICE IS WRONG. YOU MAY ALSO ASK FOR A STATE HEARING. “YOUR
HEARING RIGHTS” FORM ON THE BACK SIDE OF THIS PAGE TELLS YOU HOW TO ASK FOR A STATE HEARING.
Rules:
These rules apply; you may review them at your welfare office: MPP Sections 42-302.1, 42-302.11, 42-302.12, 42-302.2,
42-302.3 - .34 and Senate Bill 72 (Chapter 8, Statutes of 2011).
CW 2190B (5/16) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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