Forms 1.0
Providers must sign this agreement form.
What is the DPSS 2719?
This form serves as the official CalWORKs Stage One CC application form.
What is the EESD 9600?
This form provides the required 8 key data elements to RCOE when transferring families from Stage One to Stage Two.
What is the DPSS 2985?
This form is used to notify parents/caretakers that their recertification is due.
What is the DPSS 3155?
This NOA is sent when CC services are approved.
What is the NA 832?
This form is used to gather Licensed Provider information.
What is the DPSS 3007B?
This form is used to inform parents/caretakers of the availability of paid CC services.
What is the CCP 7?
This form is used to log processed reimbursements on a daily basis.
What is the DPSS 3576?
This form is used to inform providers of fraud.
What is the DPSS 512CP?
This NOA is sent to the parent when a CC change has been processed.
What is the NA 833?
This form is used to gather License-Exempt Provider information.
This form is used to inform parents/caretakers of fraud.
What is the DPSS 512C?
This form is used to notify providers of CC changes.
What is the DPSS 3057?
This form is the Health and Safety Self-Certification for License-Exempt providers.
What is the CCP 4?
This NOA is sent to the parent when CC services are discontinued.
What is the NA 835?
This form is used for Licensed Providers to declare their non-operational days.
What is the DPSS 4150?
This form is used to notify parents/caretakers of their CC authorization.
What is the CCP 8?
This form is the only valid method for parents/caretakers and providers to request for the provision of CC services.
What is the DPSS 2145?
This form is used to notify parents of the TrustLine Requirements for License Exempt providers.
What is the DPSS 3862?
This form is used as a referral to Stage Two when the parent/caretaker is not aided, but has received CW in the last 24 months.
What is the DPSS 4414?
This form is used to gather tax ID and certification information.
What is the W-9?
This form is used for the parent/caretaker to declare their preferred language/special needs.
What is the DPSS 3167?
This form is used to document relatedness between providers and children.
What is the DPSS 750C?
This is the only acceptable application for Stage One CC Providers.
What is the TLR 9163G?
This form is the only valid method for parents/caretakers and providers to request reimbursement for the provision of CC services.
What is the CSF 137?