
ADDRESS OF COUNTY WELFARE DEPARTMENT
TELEPHONE NO.: ( ) ----
■■
RCA MANDATORY REFERRAL
■■
CalWORKs MANDATORY REFERRAL
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SERVICE PROVIDER
REFERRAL / NOTIFICATION FORM
DISTRIBUTION:
Original Copy: Client
1st Copy : Service Provider
2nd Copy : Return to County Welfare Department When Notification is Required
3rd Copy : County Welfare Department
COUNTY USE ONLY
SERVICE PROVIDER USE ONLY
1. CASE NAME
FROM:
2. AU SIZE
COUNTY/DISTRICT
PREVIOUS SERVICE PROVIDER:
3. AID CODE/CASE NUMBER
4. REGISTRANT’S NAME
5. SOCIAL SECURITY NUMBER
6. ALIEN NUMBER
7. DATE OF ENTRY AS A REFUGEE, OR DATE GRANTED ASYLUM, OR DATE OF CERTIFICATION AS A
TRAFFICKING VICTIM
8. INTRACOUNTY OR INTERCOUNTY TRANSFER
10. DATE OF REFERRAL
AUTHORIZED SIGNATURE DATE
WORKER’S SIGNATURE WORKER’S NUMBER
DATE
DATE
13. COMMENTS
18. COMMENTS
19. SERVICE PROVIDER AUTHORIZED SIGNATURE
RS 3 (10/03)
9. SPECIFY PRIMARY LANGUAGE DESIGNATED ON SAWS 1
A -
11. YOU ARE REQUIRED TO REPORT TO THE SERVICE PROVIDER
BEFORE YOU CAN BE ELIGIBLE FOR CASH ASSISTANCE.
a. ■■ PLEASE TAKE THIS FORM TO THE FOLLOWING SERVICE
PROVIDER AND RETURN TO YOUR WORKER WITH DATED
ORIGINAL ON OR BEFORE _______________ .
b. ■■ YOUR APPOINTMENT AT THE SERVICE PROVIDER IS
SCHEDULED FOR:
DATE:_________________ TIME:_________________
12. SERVICE PROVIDER ADDRESS
TELEPHONE NO.: ( ) ---
I certify that I have informed the applicant/recipient of his or her rights and responsibilities in regard to the RCA/ECA programs. I have explained
that he/she must comply with all eligibility requirements, such as reporting to, and registering with the Service Provider,
and participating and cooperating in training and employment activities, and that, if these requirements are not met, he/she may lose their grant.
15. Individual reported to Service Provider as required.
16. SERVICE PROVIDER EMBOSSING STAMP
When the above named registrant has completed participation in the training program or been
placed in employment, please complete the 1st and 2nd copies and return the 2nd copy to the
county welfare department addressed above.
17. Reason for notification to the county welfare department:
■■ Other
(Explain in COMMENTS section)
■■ Client has completed participation in training.
(see attached RS 3A)
■■ Client has been placed in employment on ______________________
(see attached RS 3A) DATE
14.