Domestic Abuse Forms

Authorization For Release of Information (SCD 1029)

The SCD 1029 is used as a release to obtain information to assist the client in identifying and removing barriers to employment and self-sufficiency.

Permission to Release Domestic Abuse Information When Moving to Another County (WTW 37)

The WTW 37 must be provided to recipients who have been identified as victims of domestic abuse at the time they are identified and at their annual redeterminations. The recipient must be informed that if they move to a new county and have not signed the WTW 37 form, any information regarding their domestic abuse situation cannot be transferred to the receiving county unless they sign a new WTW 37 form in the receiving county.

CalWORKs Domestic Abuse Participation Status (SCD 1554)

The CalWORKs Social Worker (SW)/Domestic Violence (DV) Advocate uses the SCD 1554 to offer the client the opportunity to utilize the following options:

Domestic Abuse Exemption/Extender Determination
- Refer to the CalWORKs Domestic Abuse Participation Status (SCD 1554) topic in CWES Handbook Chapter 17 for more information.
Child Support Domestic Abuse Good Cause
- The CalWORKs SW/DV Advocate will advise the client of the option of claiming “Good Cause” due to domestic abuse in order to prevent a child support referral to the Local Child Support Agency (LCSA) to establish paternity and child support.
- The CalWORKs SW/DV Advocate will also advise the client of domestic abuse waivers of child support and paternity establishment.
Alternate Mailing Address/Safe at Home (SAH) Program
- If the client chooses to use an alternate mailing address, P.O. Box number, or telephone number, they must complete the "Client Completes for Alternate Mailing Address" section of the SCD 1554.
- If the client is enrolled in the SAH program, this information is accepted and recorded by the Eligiblity Worker (EW). The middle section of the SCD 1554 must still be completed by the client.
- For more information on the SAH program, refer to Common Place Handbook SSA Protective and Supportive Services Overview.
- Exception: When factors affecting eligibility or apparent eligibility, such as in cases of immediate need, diversion, or suspected fraud, cannot be satisfactorily determined, the applicant/recipient is required to provide the actual residence address. This information is to be maintained in the case file only and must not be entered on any computer/automated system. Continue to use the Safe at Home P.O. Box and fictitious street address on all computer-generated documents.

EW and AEC/EC Coordinated Review and Action

When the SCD 1554 is received from the CalWORKs SW/DV Advocate, the EW and Associate Employment Counselors (AECs)/Employment Counselors (ECs) must review the form and take the following actions:

EWs

Add the case flag "Domestic Abuse" and enter an end-date 30 days out.
Enter the alternate mailing address, if one is provided.
Sign and date the bottom of the SCD 1554.
E-mail a completed copy of the SCD 1554 to the AEC/EC and the CalWORKs SW/DV Advocate.
Receive e-mail notification from the AEC/EC that the Maintain Participant Activity window in CalSAWS has been updated with the activity:
1. "Domestic Abuse SV" activity for exemptions, or
2. Extender-Domestic Abuse Service for Extenders, and Registration status of “Exempt” with Exemption Reason of “Manual Exemption: Domestic Abuse (CalWORKs 60-month time limit waiver).
Run EDBC.

AECs/ECs

Refer to the CalWORKs Domestic Abuse Participation Status (SCD 1554) topic in CWES Handbook Chapter 17.

CalWORKs Domestic Abuse Service Plan (SCD 1555)

Refer to the Individual Service Plan and Case Assessment topic in CWES Handbook Chapter 17 for information on SCD 1555.