For a list of MCED forms by form number, please click on the following link: MCED Forms by Number. English | Spanish | Request accessible version. Proficient in medicine (prevention), digital health consulting, clinical decision support system (CDSS), clinical data sciences and program management. Report welfare fraud to the California Department of Social Services (CDSS) Welfare Fraud Hotline at 800-344-8477 , or DPSS Central Fraud Reporting Line at 800-349-9970 , or at lacounty . bury grammar school staff list. PUB 403 (1/13) - English and Spanish - We Accept EBT - EBT Retailers Posters ; PUB 403A (1/13) - English and . 3. 4. [1] [2] [3] Substances range from a variety of plants, spices, foods, and synthetic chemicals. California Foster Youth Education Law Fact Sheets in Spanish (PDF) The Foster Youth Definitions (XLSX) document provides reference information on the educational supports and entitlements for foster youth. Cantonese. If you suspect a case of child abuse in your neighborhood, you should contact your county child welfare agency or local law enforcement agency. Rena toda la documentacin para presentar su solicitud. Security Awareness. Problems with downloading forms? English | Spanish. Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Rules of Court, rule 5.481 . Application for Services Forms. If you answered "YES" to both Question #1 AND #2, respond to Questions #3 and #4 below, and complete the certification in PART D at the bottom of the form. 48 close to the numerical solution and major trends of the well BHP and average . CD-278-Spanish: Safe Sleep Flyer - Spanish: None: Case Management/Licensing/Resource Development: No: No: 10/21: CS2-ATT Spanish: Parent Response Form: None: Case . KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds ; KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program . Provide a description of any physical and/or mental condition or functional limitation that has . Statewide Information Management Manual (SIMM) 5310 - A & B. All questions and comments are moderated and publicly viewable. For personal information access requests, send an email to CDSS' Public Inquiry and Response Unit [email protected] and/or call (916) 651-8848. Form Adopted for Mandatory Use Judicial Council of California ICWA-020 [Rev. Home Supportive (IHSS) Fact Sheets - Spanish. MC 210 A (09/07) - Supplement to Statement of Facts for Retroactive Coverage/Restoration. CHDP Referral - PM 357. Third Party Liability Notification. . Spanish Version English Version Add to Cart; CPS 04: Mandatory Reporting Brochure: n/a: n/a: CPS 11: Central Registry Brochure: n/a: n/a: CPS-501: Individual: Request for Screening: n/a: n/a: n . PUB 240 (1/04) - Continuing Care Retirement Communities in California (Printing), PUB 240 (1/04) - Continuing Care Retirement Communities in California (Viewing), PUB 269 (2/18) - California Child Passenger Safety Law-(8.5" x 11"), PUB 269 (2/18) - California Child Passenger Safety Law - (8.5" x 14"), PUB 271 (2/17) - Never Shakea Baby Brochure, PUB 271 (2/17) - Never Shake a Baby Brochure (Black & White), PUB 273-A2 (2/21) -Shaken Baby Syndrome Poster - ( 24" x 36"), PUB 275 (4/07) - Family Planning - Making the Commitment for a Healthy Future, PUB 294 (6/21) - Assistance Dog Special Allowance (ADSA) Program Fact Sheet, PUB 294L (6/21) - Assistance Dog Special Allowance (ADSA) Program Fact Sheet, PUB 325 (12/16) - Your Right To Make Decisions About Medical Treatment (Print 8 1/2 X 14), PUB 326 (8/22) - Facts You Needs to Know - Group Home and Short-Term Residential Therapeutic Program - Board of Directors or Governing Body, PUB 337 (9/12) - Statewide Fingerprint Imaging System (SFIS), PUB 339 (7/13) - Foster Care Ombudsman Brochure, PUB 341 (4/16) - Adoptions Services Bureau Career Opportunities, PUB 367 (4/13) - Reach For Your Dreams With Cal-Learn, PUB 370 (4/19) - Public Assistance Benefits For Asylees In California, PUB 370 (1/21) - Public Assistance Benefits For Asylees In California, PUB 373 (Print 8 1/2 X 11) (5/07) - Important Food Stamp Information For Noncitizens, PUB 373 (Print 11 X 17) (5/07) - Important Food Stamp Information For Noncitizens, PUB 388 (8/17) - California Electronic Benefit Transfer (EBT) Card. On-line Forms and Publications M - P. M | N | O . Desired Results Developmental Profile (2015) (PDF; 1MB) Infant/Toddler View for use with infants and toddlers. Electronic theft is any loss of cash benefits taken by an unauthorized withdrawal or use of benefits that does not occur with the use of a physical EBT card issued to the benefit recipient or authorized third party to directly access the benefits. For personal information access requests, send an email to CDSS Public Inquiry and Response Unit [email protected] and/or call (916) 651-8848. AD 898 (1/11) - Consent Of CDSS Or Delegated County Adoption Agency - Independent Adoptions Program ; AD 899 (3/08) - Statement of Understanding - Mother or a Presumed Father of the Indian Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or a Ward of a Legal Guardian . 1 - 25 of 62 Forms. Claim Your 2022 State And Federal Credits - You Earned It - It's Your Money, PUB 438 (11/15) -TrustLine Parent Pamphlet, PUB 439 (11/15) - License Exempt Provider Pamphlet, PUB 456 (3/11) - Important Information For Relatives Pamphlet (Requires 8 1/2" x 14" paper printed landscape), PUB 461 (1/22) - Join The California Department of Social Services Volunteer Emergency Services Team (VEST), PUB 462 (6/22) - Join The Functional Assessment Service Team (FAST), PUB 463 (10/13) - Education Travel Reimbursement, PUB 468 (10/16) - Approved Relative Caregivers Funding Option Program, PUB 470 (4/21) - Your Rights Under Adult Protective Services, PUB 472 (6/21) - Parent Appeal Information Pamphlet, PUB 474 (12/14) - Rights of Resident Councils, PUB 475 (10/18) - Residential Care Facility for the Elderly (RCFE) Complaint Poster, PUB 484 (7/15) - Keep More Of Your Money - Poster, PUB 488 (2/16) - Foster Youth Mental Health Bill of Rights - Questions to Ask About Medications, PUB 490 (4/18) - Know Your Sexual and Reproductive Health Rights, PUB 500 (5/20) - Complaint Investigation Process - Statewide Children's Residential Program - State Licensed Foster Parents, PUB 501 (2/16) - Complaint Investigation Process - Statewide Children's Residential Program -County Licensed Foster Parents, PUB 502 (5/20) - Complaint Investigation Process - Statewide Children's Residential Program - Foster Family Agency Certified Parents, PUB 511 (8/19) - Finding A Competent Therapist, PUB 515 (10/19) - Risks and Effects ofLead Poisoning, PUB 516 (9/19) - You May Be Eligible For 12 Months Of Child Care, PUB 520 (11/21) - Great News! MC 210 A (09/07) (Formerly MC 213) Page 1 of 3 . Public Records Act - Government Code section 6250 et seq. Security Awareness, Copyright 2023 California Department of Social Services. For additional resources, go to IHSS Recipient/Consumer Resources. **Due to browser constraints please download forms for full functionality. ATTORNEY OR PARTY WITHOUT ATTORNEY . Required Form - Substitute with Prior CDSS Approval - Section 23-400.112, Management and Office Procedures - Forms Management Forms in this category are required forms for which modifications or substitutions are permitted with the prior approval of the California Department of Social Services (CDSS). CDSS.docx. Health Insurance Premium Payment Program. Averige si califica. **Due to browser constraints please download forms for full functionality. FCCH - Pre-Orientation Registration Information: Wait! PUB 223 (1/04) - So, You Want To Open A Group Home For Children? DFA 285D (8/11) - CalFresh Budget . 6. In-Home Supportive Services (IHSS) In-Home Supportive Services, also known as IHSS, can help pay for services if you're a low-income elderly, blind or disabled individual, including children, so that you can remain safely in your own home. On 3/14/2022, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1 Year inspection at the Velasco Family Child Care.Family members residing in the home are three adults (licensee, two adult renters who utilize the separate section of the house property-separated by a common wall which is the off-limits television room). rest of the form including the certification in PART D at the bottom of the form. Search more forms. dobitie kreditu tesco mobile. NA Back 9 (5/22) - Your Hearing Rights (Full Rights Are Listed in CDSS PUB 412) NA Description Of Services L (3/15) - Description . Part A: Tell us about you: Applicant. Application for Child Support Services. For IHSS Required forms: No accommodation is needed . Medi-Cal Eligibility Division Translated Forms Back to Forms by Program Medi-Cal Eligibility Division (MCED) forms are listed below in alphabetical order by language. Japanese. www.courts.ca.gov. MC 300 Forms: MC 306 (11/15) - Appointment of Representative; Alt: Spanish (01/08) MC 322 (05/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application Spanish. Welfare and Institutions Code section 10850. Here's How, CW 2184 (8/16) - CalWORKS 48-month Time Limit, CW 2184 (4/21) - CalWORKs 60-Month Time Limit, CW 2186A (12/12) - CalWORKs Exemption Request Form, CW 2186A (4/21) - CalWORKs Exemption Request Form, CW 2186B (4/21) - CalWORKs Exemption Determination, CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit, CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit, CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program, CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42nd Month On Aid, CW 2189A (9/20) Notice Of Your CalWORKs Time Limit 54TH Month On Aid (Use Starting May 1, 2022), CW 2189B (9/20) Notice Of Your CalWORKs Time Limit 57TH Month On Aid (Use Starting May 1, 2022), CW2190A (4/16) - CalWORKs 48-Month Time Limit Extender Request Form, CW2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form, CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form, CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits, CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2205 (10/12) - New Rules For CalWORKs Welfare-To-Work Activities, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (12/20) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child) - Use Starting June 1, 2021, CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2219 (5/16) Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child), CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs, CW 2224 (2/20) - CalWORKs Home Visiting Initiative (HVI), DFA 377.1A (3/02) - Notice Of Denial Or Pending Status, DFA 377.7A (4/21) - Notice Of Administrative Disqualification, DFA 377.7D2 (10/00) - Food Stamp Repayment Notice for Administrative Errors Only, Final Notice, DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only, DFA 377.7F (6/18) - CalFresh Overissuance Notice For An Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IVP, DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV)Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Discontinuance, DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 421 (7/99) - Notification Of Open Record And Waiver Of Time, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/Food Stamps, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (1/23) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A ENG/SP (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (3/23) - The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, EFA 15 (3/23) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, FC 2 (11/04) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC), FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC), FC 31 (8/16) Accreditation Reimbursement Request. , spices, foods, and synthetic chemicals Council of California ICWA-020 Rev... - Spanish - So, You Want to Open A Group home for?! 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