Transcription of EMERGENCY ASSISTANCE APPLICATION FOR COUNTY …
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EMERGENCY ASSISTANCE APPLICATION FOR COUNTY …
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 NAMEC hildatRiskRelatedHead 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 BIRTHT elephone 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.)
INSTRUCTIONS FOR COMPLETING THE EMERGENCY ASSISTANCE (TITLE IV-A) APPLICATION PRIMARY AND SUPPLEMENTAL APPLICATION- Check the box which indicates the status of the application.If this is a primary application, the entire application must be completed.
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