STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
WELFARE-TO-WORK (WTW) 24-MONTH
TIME CLOCK EXTENSION DETERMINATION
OTHER ID NO.
Questions? Ask your worker.
On _______________ , _________________________________________ asked for an extension of the WTW 24-Month Time Clock.
Based on the information you have provided, the county made the following decision:
This extension is APPROVED. Reason for extension: ______________________________________________________________
This means that you can continue to be in the activities in your current welfare-to-work plan for more time.
Your extension will end on ________________________ .
Your condition may be reviewed again to see if you should continue to get an extension. If your extension ends, you will need to
change the activities in your welfare-to-work plan to meet CalWORKs federal standards.
If your extension should continue, you may need to provide information to the county to show that it should continue before the
ending date above, or you will need to meet CalWORKs federal standards.
You can change the activities in your welfare-to-work plan to meet CalWORKs federal standards at any time by contacting your
worker and signing a new welfare-to-work plan.
This extension is DENIED. Reason for denial: ___________________________________________________________________
You must meet CalWORKs federal standards once you have used all 24 months of your WTW 24-Month Time Clock. You will get
a notice from the county about changing the activities in your welfare-to-work plan to meet CalWORKs federal standards.
CONTACT YOUR WORKER RIGHT AWAY IF YOU:
• Need more information about CalWORKs federal standards that you must meet once you have used all of your WTW 24-Month
Time Clock months.
• Think you should not be in Welfare-to-Work and have not asked for an exemption, or need more information about exemptions
from participation in Welfare-to-Work.
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.
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WTW 45 (1/15) REQUIRED FORM - NO SUBSTITUTE PERMITTED