Right Column
On-line Forms and Publications A - D
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- AAP 1 (06/01) - Request For Adoption Assistance (With Calculation)
- AAP 1 (06/01) - Request For Adoption Assistance (Without Calculation)
- AAP 2 (08/01) - Payment Instructions Adoption Assistance Program
- AAP 3 (06/01) - Reassessment Information Adoption Assistance Program
- AAP 4 (08/99) - Eligibility Certification Adoption Assistance Program (Combines AAP4 And FC 9)
- ABCD 239.7A (08/01) - Notice Of Administrative Disqualification California Work Opportunity And Responsibility To Kids (CalWORKs) Program
- ABCD 478A (5/02) - Disqualification Consent Agreement California Work Opportunity And Responsibility To Kids (CalWORKs) Program
- ABCDM 228 (06/99) - Applicant's Authorization For Release Of Information
- AD 1A (08/02) - Consent To Adoption By Parent(s) (In California)
- AD 1C (3/08) - Consent By Parent(s) Outside California
- AD 1F (3/08) - Consent To Adoption By Parent(s) Outside California In Armed Forces
- AD 2 (06/02) - Stepparent Adoption (Consent To Adoption By Parent Retaining Custody
- AD 2A (06/02) - Stepparent Adoption (Consent To Adoption By Parent In California Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent)
- AD 2B (3/08) - Consent To Adoption By Parent Outside California Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent
- AD 2D (3/08) - Stepparent Adoption Consent To Adoption By Parent Outside California In Armed Forces Giving Custody To Husband Or Wife Or Domestic Partner Of Other Parent
- AD 8 (10/01) - Marriage/Divorce Verification (Combined With AD 19)
- AD 9 (11/07) - Independent Adoption Questionnaire
- AD 10 (9/03) - Request for Reference
- AD 20 (3/08) - Refusal To Give Consent To Adoption
- AD 20B (3/08) - Refusal To Give Consent To Adoption - Alleged Natural Father
- AD 22 (07/02) - Health Facility Minor Release Report
- AD 28 (08/03) - Notification Of Subsequent Action
- AD 29 (3/07) - Employment Verification
- AD 40.1 (8 /03) - Adoptions wooksheet (Print 8 1/2 x 14)
- AD 42 I (03/02) - Independent Adoptions Program (Individual Case Report)
- AD 42R (10/00) - Agency Adoption Program - Individual Case Report
Use legal size paper to print - AD 56A (10/01) - Agency Adoption Program Quarterly Statistical Report (Combines AD 56A, AD 56C, And AD 56E)
- AD 56D (01/02) - Independent Adoption Program & Adoption Set Asides
- AD 65 (2/02) - Parent's Authorization For Medical And Surgical Care
- AD 67 (2/07) - Information about The Birth Mother
- AD 67A (6/07) - Information About The Birth Father
- AD 90 (7/06) - Supporting Information For Issuance Of California Department Of Social Services Acknowledgement And Confirmation Of Receipt Of Child Freeing Documents
- AD 100 (2/08) - Authorization For Use And/Or Disclosure Of Health Information Independent Adoption Program
- AD100A (3/08) - Authorization For Use And/Or Disclosure Of Health Information Agency Adoption Program
- AD 165 (8/02) - Presumed Father's Consent To Adoption (In California)
- AD 166 (3/08) - Consent To Adoption By Father Outside California - TO BE USED WHEN PRESUMED FATHER DENIES HE IS THE NATURAL FATHER
- AD 196 (02/02) - Request For Release Of Information
- AD 200 (1/02) - Request For Case Record/Documents
- AD 202B (01/02) - Intercounty Adoption Program Quarterly Statistical Report
- AD 501 ENG/SP (09/03) - Relinquishment In or Out-of-County (Birth Mother/Presumed Father in California)
- AD 501A (3/08) - Relinquishment Out-of-State (Birth Mother/Presumed Father)
- AD 504 (9/03) - Relinquishment – Out of State In The Armed Forces (Birth Mother/Presumed Father)
- AD 508 (9/03) - Rescission Request/Rescission Of Relinquishment
- AD 512 (03/99) - Psychosocial And Medical History Of Child - English Version
- AD 521 (09/03) - Application For Adoption Of A Child
- AD 524 (Bilingual) (03/99) - Physician's Examination Of Adoption Applicant/Petitioner
- AD 551A (06/99) - Notification Of Procedure In Lieu Of Signing Relinquishment, Waiver or Denial (To Be Used For California Court Actions, Out-of-State Actions, And Foreign Born Children)
- AD 558 (6/05) - Notice Of Placement (To Be Sent Within 15 Days of Placement)
- AD 580 (12/99) - Notice of Removal Of Child From Adoptive Home
- AD 583 ENG/SP (3/08) - Relinquishment In Or Out Of County - Presumed Father Denies He Is The Birth Father in California
- AD 584 (3/08) - Relinquishment Out of State - Presumed Father Denies He is the Birth Father
- AD 586 (3/08) - Relinquishment In or Out-of-County (Alleged Natural Father In California)
- AD 588 (3/08) - Denial Of Paternity By Alleged Natural Father (In Or Out Of California)
- AD 590 (3/08) - Waiver Of Right To Further Notice Of Adoption Planning - Alleged Natural Father In Or Out Of California
- AD 590A (3/08) - Waiver Of Right To Further Notice Of Adoption Planning - Presumed Father In Or Out Of California
- AD 591 (3/08) - Relinquishment Out-of-State (Alleged Natural Father)
- AD 593 (9/03) - Relinquishment – Out of State in Armed Forces (Alleged Natural Father)
- AD 594 (3/08) - Alleged Natural Father's Consent To Adoption (In Or Out Of California)
- AD 824 (3/00) - Adoption Petition - Consent and Joinder
- AD 830 (06/99) - Summary Claim For Reimbursement Private Adoption Agency Reimbursement Program (Welare Institutions Code Section 16122)
- AD 836 (05/99) - Report Of Physician Attending Birth Of Child Placed For Adoption
- AD 842 (08/02) - Consent To Adoptive Placement By Alleged Natural Father (Outside California In Armed Forces)
- AD 859 (08/02) - Consent To Adoption Of Indian Child By Parent(s) (In Or Out Of California)
- AD 860 (08/02) - Consent To Adoption Of Indian Child By Presumed Father (In Or Out Of California)
- AD 861 (08/02) - Consent To Adoption Of Indian Child By Alleged Natural Father (In Or Out Of California)
- AD 862 (3/08) - Relinquishment Of An Indian Child Out of State - Alleged Natural Father
- AD 863 (3/08) - Relinquishment Of An Indian Child Out of State - Birth Mother/Presumed Father
- AD 864 (3/08) - Relinquishment Of An Indian Child In Or Out-Of-County - Birth Mother/Presumed Father In California
- AD 866 (3/08) - Relinquishment Of An Indian Child In Or Out-of-County - Presumed Father Denies He Is The Birth Father In California
- AD 867 (3/08) - Relinquishment of an Indian Child - Out-of-State - Presumed Father Denies He is the Birth Father
- AD 868 (3/08) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California
- AD 880 (03/99) - Declaration Of Mother (To Be Completed By All Mothers Not Married To The Father Except When A Relinquishment Or Consent Has Been Obtained From The Father)
- AD 885 (3/06) - Mother Or A Presumed Father Of A Child Who Is Not Detained, A Juvenile Court Dependent In Out-of-home Care, Or The Ward Of A Legal Guardian
- AD 885A (3/06) - Mother or a Presumed Father of a Child Who is Detained, a Juvenile court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
- AD 885C (3/06) - Statement of Understanding Agency Adoptions Program - Alleged Natural Father Of The Child Who Is Not Detained, A Juvenile Court Dependent In Out-Of-Home Care, Or The Ward Of A Legal Guardian
- AD 885D (3/06) - Alleged Natural Father of the Child Who is Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal Guardian
- AD 887 (3/06) - Statement Of Understanding - Independent Adoptions Program
- AD 887A (3/06) - Statement Of Understanding - Parent Who Did Not Give Physical Custody (Non-Custodial Parent) Of The Child To The Petitioner(s)
- AD 887B (3/08) - Statement of Understanding - Alleged Natural Father
- AD 899 (3/06) - 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
- AD 899A 3/06) - Statement of Understanding - Mother or a Presumed Father of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
- AD 899C (3/06) - Statement Of Understanding - Alleged Natural Father of the INDIAN Child Who is Not Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
- AD 899D (3/06) - Statement Of Understanding - Alleged Natural Father of an INDIAN Child Who is Detained, a Juvenile Court Dependent in Out-of-home Care, or the Ward of a Legal Guardian
- AD 900 (3/06) - Statement Of Understanding Independent Adoptions Program – Parent Who Gave Physical Custody (Custodial Parent) of the INDIAN Child to the Petitioner(s)
- AD 900A (3/06) - Statement of Understanding Independent Adoptions Program - Parent Who Did Not Give Physical Custody (non-custodial) Of The Indian Child To The Petitioner(s)
- AD 900B (3/06) - Statement of Understanding – Alleged Natural Father of INDIAN Child
- AD 904 (6/07) - Consent For Contact
- AD 904A (9/07) - Waiver of Rights to Confidentiality For Siblings
- AD904B (4/08) - Waiver Of Rights To Confidentiality For Siblings - Under The Age Of 18
- AD 907 (08/03) - Adoptive Placement Agreement
- AD 908 (10/04) - Adoptions Information Act Statement
- AD 908A (3/06) - Adoptions Information Act Statement
- AD 909 (12/99) - Photo Listing Data Sheet
- AD 918 (11/03) - Family Assessment Questionnaire II
- AD 922 (07/99) - Relinquishment Addendum For Parent Identifying Adopting Parent(s)
- AD 924 (4/08) - Independent Adoption Placement Agreement
- AD 925 (4/08) - Independent Adoption Placement Agreement - INDIAN Child
- AD 926 (10/03) - Statement Of Understanding Independent Adoptions Program – Parent Who Places The Child With The Prospective Adoptive Parent(s)
- AD 927 (9/03) - Statement Of Understanding - Independent Adoptions Program
- AD 928 (07/02) - Revocation Of Consent Independent Adoption Program
- AD 929 (08/02) - Waiver Of Right To Revoke Consent Independent Adoption
- AD 930 (05/99) - Independent Adoption Placement Agreement Transmittal Report
- AD 4310 (10/99) - Adoption Programs Notice Required By Information Practices Act
- AD 4313 (08/03) - Letter Requesting Parent Be Interviewed
- AD 4315 (8/03) - Recommendation Of Dismissal Of Petition Court Report Outline
- AD 4317 (10/99) - Revocation Of Relinquishment
- AD 4320 (04/08) - Adoption Assistance Program (AAP) Agreement
- AD 4324 (10/03) - Adoption Questionnaire I This is a large PDF file. Click here if you have problems with it: Tips for Using Adobe PDF Files
- AD 4328 (03/06) - Authorization For Release Of Personal Items
- AD 4336 (09/02) - Presumed Father's Consent To Adoption (Outside California In Armed Forces)
- AD 4339 (3/06) - Relinquishment – Out of State (Birth Mother/Presumed Father)
- ADM 36 (06/99) - Medical Report Regarding Child To Be Adopted
- ADSA 1 (06/01) - Assistance Dog Special Allowance Application
- ADSA 1A (10/98) - Assistance Dog Special Allowance Renewal Application
- ADSA 1B (06/01) - Assistance Dog Special Allowance (ADSA) Application For Social Security Disability Insurance (SSDI) Recipients
B Forms
C Forms
- CCP1 (01/08) - Declaration Of Exemption From Trustline Registration And Health And Safety Self-Certification
- CCP4 (01/08) - Health And Safety Self-Certification (For license-exempt providers)
- CCP6 (08/99) - Health And Safety Checklist
- CCP7 (01/08) - CalWORKs Stage One Child Care Request Form And Payment Rules
- CCP 2145 (5/04) - CalWORKs Child Care Reimbursement Report
- CD 9600 (12/99) - Confidential Application For Child Development Services And Certification Of Eligibility
- CEF Q05 (5/05) - Speech And Language Evaluation Form
- CEF Q08 (11/04) - Report Of Ophthalmological Examination
- CL 1 (04/99) - Cal-Learn Registration Program Information Orientation Appointment
- CL 2 (04/99) - Cal-Learn Program Requirements
- CL 3 (04/99) - Cal-Learn Notice Of A Participation Problem
- CL 4 (04/99) - Cal-Learn Notice To Parent/Legal Guardian Of Cal-Learn Participant
- CL 8 (03/99) - Cal-Learn Notice Of Report Card Submittal Schedule
- CL 9 (03/99) - Cal-Learn Notice Of Good Cause Determination
- CL 10 (04/99) - Cal-Learn Notice Of Exemption/Deferral
- CL 11 (04/99) - Cal-Learn Notice Of Incomplete Grades
- CL 15 (1/00) - Cal-Learn Case Management Information Intercounty Transfer Form
- CL 16 (1/00) - Cal-Learn Case Management Inter-County Transfer Summary
- CW 2.1 N A(8/04) - Notice And Agreement For Child, Spousal And Medical Support
- CW 2.1Q (07/01) - Support Questionnnaire
- CW 4 (06/02) - Immediate Need Payment Request
- CW 5 (07/01) - Veterans Benefits Verification and Referral
- CW 8 (07/01) - Statement of Facts For An Additional Person
- CW 8A (03/00) - Statement Of Facts To Add A Child Under 16
- CW 10 (07/01) - Notice of Withdrawn Application
- CW 13 (09/02) - Caretaker Relative Agreement
- CW 23 (03/00) - Senior Parent Statement Of Facts
- CW 25 (07/01) - Supplemental Statement of Facts - Minor Parent
- CW 31 (5/04) - Receipt For Documents
- CW 40 - CalWORKs (03/00) - Reduced Income Supplemental Payment Request
- CW 42 (11/06) - Statement of Facts - Homeless Assistance
- CW 43 (03/00) - CalWORKs Applicant Choice Form Immediate Need Payment/Expedited Grant
- CW 51 (11/04) - Child Support - Good Cause Claim For Noncooperation
- CW 60 (05/01) - Release Of Information - Financial Institution
- CW 61 (07/01) - Authorization to Release Medical Information
- CW 61A (06/01) - Physical Capacities
- CW 61B (06/01) - Mental Capacities
- CW 63 (04/01) - Income And Eligibility Verification Form
- CW 71 (03/00) - Statement Of Cash Aid Mother An Unrelated Adult Male (UAM)
- CW 81 (07/01) - Lien Agreement
- CW 82 (03/00) - Coversheet - Agreement To Sell Property
- CW 86 (03/00) - Agreement - Restricted Account California Work Opportunity And Responsibility To Kids (CalWORKs) Program
- CW 87 (06/02) - Reinforming Letter/Add a Person(s)Program
- CW 88 Coversheet (05/00) - You May Be Eligible For Diversion Services
- CW 88 (05/00) - Diversion Services Agreement CalWORKs Program
- CW 89 (02/03) - Application Withdrawl Request
- CW 103 (07/99) - Transitional Medi-Cal
- CW 215 (12/05) - Notification Of Intercounty Transfer
- CW 215A (3/04) - CalWORKs Intercounty Transfer Continuation Request For Additional Documents
- CW 371 (07/01) - Referral To Local Child Support Agency (LCSA)
- CW 801 (11/00) - Summary Report Of Performance Incentives For Grant Reductions Due To Employment Earnings And Diversion For The California Work Opportunity And Responsibilities To Kids (CalWORKs)
- CW 801.2 (02/00) - California Work Opportunity And Responsibility To Kids (CalWORKs) Diversion Grant Summary
- CW 2102 (08/00) - The Maximum Faily Grant (MFG) Rule For Recipients Of Cash Aid
- CW 2166 (11/06) Multilingual - Work Pays Notice
- CW 2184 (11/02) - CalWORKs 60-Month Time Limit
- CW 2186A (12/05) - CalWORKs Time Limit and Welfare to Work Participation Exemption Request Form
- CW 2186B (06/04) - CalWORKs and Welfare to Work Time Limit Exemption Determination
- CW 2187 (06/04) - YOUR CalWORKs 60-Month Time Limit
- CW 2188 (04/02) - Verification of Aid for Temporary Assistance for Needy Families (TANF) Program
- CW 2189 (06/02) - Notice of your CalWORKs Time Limit 54th Month on Aid
- CW 2190A (06/04) - CalWORKs 60-Month Time Limit Extender Request Form
- CW 2190B (06/04) - CalWORKs 60-Month Time Limit Extender Request Form
- CW 2191 (06/04) - Time on Aid Verification/60 month Time limits
- CW 2192 (06/04) - Tracking Non-CA TANF Asst.- 60 Month Time Limit
D Forms
- DFA 285-A1 (1/07) - Application For Food Stamp Benefits
- DFA 285-A2 (8/06) - Statement Of Facts
- DFA 285-A3 QR (5/06) - Food Stamp Benefits Your Rights And Responsibilities
- DFA 285B (8/07) - Food Stamp Budget Worksheet/Change Reporting Household
- DFA 285C (04/99) - Food Stamp Supplemental Application For Special Medical Deductions
- DFA 285D (8/07) Food Stamp Budget Worksheet - Special Medical/Shelter Deductions
- DFA 303 (03/05) - Replacement Affidavit/Authorization
- DFA 377.1 (11/01) - Notice of Approval
- DFA 377.1A (03/02) - Notice Of Denial Or Pending Status
- DFA 377.4A (07/03) - Food Stamp Notice of Change
- DFA 377.4 QR (1/04) - Food Stamp Notice Of Change For Change Reporting Household
- DFA 377.5 (8/06) - Food Stamp Household Change Report
- DFA 377.7A (07/99) - Notice Of Administrative Disqualification
- DFA 377.7B (12/03) - Food Stamp Repayment Notice For Inadvertent Household Errors Only
- DFA 377.7B1 (10/00) - Food Stamp Repayment Notice For Inadvertent Household Errors Only Final Notice
- DFA 377.7C (05/02) - Food Stamp Repayment Agreement For Inadvertent Household Errors Only
- DFA 377.7D (06/01) - Food Stamp Repayment Notice For Administrative Errors Only
- DFA 377.7D1 (06/01) - Food Stamp Repayment Notice For Administrative Errors Only
- DFA 377.7D2 (10/00 ) - Food Stamp Repayment Notice For Administrative Errors Only Final Notice
- DFA 377.7D3 (12/03) - Food Stamp Repayment Notice For Administrative Errors Only
- DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only
- DFA 377.7E1 (05/02) - Food Stamp Repayment Agreement For Administrative Errors Only
- DFA 377.7F (08/01) - Food Stamp Repayment Notice For An Intentional Program Violation (IPV) Or Status Change From Inadvertent Household Error (IHE) To An IVP
- DFA 377.7F1 (10/00) - Food Stamp Repayment Notice For An Intentional Program Violation (IPV) Only Final Notice
- DFA 377.7G (05/02) - Food Stamp Repayment Agreement For An Intentional Program Violation (IPV) Only
- DFA 377.9 (8/01) - Notice of Back Food Stamp Benefits
- DFA 377.10 (06/04) - Food Stamp Notice Of Discontinuance
- DFA 377.11 (9/04) - Food Stamp Notice Of Discontinuance - Failure To Meet The ABAWDs Work Rule
- DFA 377.11A (09/04) - Food Stamp Notice Of Continuance 1st Failure To Meet ABAWD Work Requirement
- DFA 385 (05/99) - Application For Emergency Food Stamp Assistance
- DFA 386 (03/02) - Notice of Missed Interview
- DFA 387 (03/02) - Request For Information
- DFA 478 (08/01) - Disqualification Consent Agreement Food Stamp Program
- DFA 842 (7/99) - Claim Determination Worksheet
- DFA 874 (10/00) - Statewide Intercounty Lost Warrant Replacement Affidavit
- DPA 13 (07/99) - Request For State Hearing Before The State Department Of Social Services
- DPA 19 (4/07) - Authorized Representative
- DPA 302 (8/07) - Interpreter/Translator Billing
- DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing
- DPA 353 (4/00) - Notice Of Aid To Families With Dependent Children (AFDC) And/Or Food Stamp Administrative Disqualification Hearing
- DPA 421 (7/99) - Notification Of Open Record And Waiver Of time
- DPA 435 (2/02) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification hearing)
- DPA 479 (12/07) - Administrative Disqualification Hearing Waiver - CalWORKs/Food Stamps
- DPA 481 (4/02)- County Report of Compliance Transmittal
- DPA 484 (07/02) - Interpreter Assignment Report
- DPA 487 (5/07) - Request For Access To Protected Health Information
- DPS 249 (01/99) - AFDC/FS Intercept County Transaction Document
- DPS 524 (03/00) - Disqualified Recipient Report
- DPS 526 (04/99) - IEVS/Payment Verification System County Response Document
- DPS 528 (4/01) IEVS/Deceased Persons Match - County Response Document