EMERGENCY ASSISTANCE APPLICATION FOR …

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CASE RECORD COPYSTATE OF california - HEALTH AND HUMAN services AGENCY california department OF social SERVICESEMERGENCY ASSISTANCE APPLICATION FORCHILD WELFARE services Primary APPLICATION Supplemental APPLICATION Date Child Determined to be at Risk (Effective Date)COUNTY NAMEChildatRiskRelatedHead ofHouse-holdChild sCaseIDInfoNAME (LAST, FIRST, )NAME (LAST, FIRST, )STREET ADDRESSCITY, STATE, ZIP CODEMAILING ADDRESS IF DIFFERENT THAN ABOVE (ADDRESS, CITY, STATE, ZIP CODE)AKA NAME(LAST, FIRST, )DATE OF BIRTHDATE OF BIRTHTelephone Number( )CWS Case Name (Last, First, )CWS CASE NUMBEROTHER ID NUMBERSOCIAL SECURITY NUMBERSOCIAL SECURITY NUMBERINFORMATION REQUIRED FOR ELIGIBILITY DETERMINATIONCERTIFICATION SECTION(Place an X in each applicable box.)

case record copy state of california - health and human services agency california department of social services emergency assistance application for

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