Domestic Abuse Forms and Supporting Documentation

CalWORKs Exemption Determination (CW 2186B)

Refer to the CW 2186B section of CWES Handbook Requesting Domestic Violence (DV) Services.

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.

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 (DA) Exemption/Extender Determination
  • Refer to the DA Exemption/Extender Determination section of CWES Handbook CalWORKs Domestic Abuse Participation Status (SCD 1554).
• Local Child Support Agency (LCSA) Child Support Good Cause
  • The CalWORKs SW/DV Advocate will advise the client of the option to claim “Good Cause” due to DA in order to prevent a child support referral to LCSA to establish paternity and child support. Refer to Common Place Handbook Good Cause Determinations for more information.
• Alternate Mailing Address/Safe at Home (SAH) Program
  • Refer to the Alternate Mailing Address/SAH Program section of CWES Handbook CalWORKs Domestic Abuse Participation Status (SCD 1554) and the SAH Program section of Common Place Handbook SSA Protective and Supportive Services Overview for more information.

EW and AEC/EC Coordinated Review and Action

When the SCD 1554 is received from the CalWORKs SW/DV Advocate, the Eligibility Worker (EW) and Associate Employment Counselor (AEC)/Employment Counselor (EC) must review the form and take the following actions:

1. The EW:
   1. If the EW made the DA referral, they must revise the End Date for the “Domestic Abuse” case flag to match the end date on the SCD 1554. Refer to the DA Case Flag section of Domestic Abuse Referral Process for more information.
   2. Enters the alternate mailing address, if one is provided.
   3. Signs and dates the bottom of the SCD 1554.
   4. E-mails a completed copy of the SCD 1554 to the AEC/EC and the CalWORKs SW/DV Advocate.
   5. Sends the SCD 1554 to Imaging.
   6. Receives a Task from the AEC/EC in the following instances:
      • A client is granted a retroactive DA exemption.
      • A client is granted a DA extension.

Important: If the client receives a Good Cause exemption before the case reaches an AEC/EC, a task would not be created. The EW must manually enter the DA time limit exemption in CalSAWS.

• Refer to Domestic Abuse Exemption/Extender for CalSAWS steps.

1. The AEC/EC:
   1. Refer to CWES Handbook CalWORKs Domestic Abuse Participation Status (SCD 1554).

CalWORKs Domestic Abuse Service Plan (SCD 1555)

Refer to the SCD 1555 section of CWES Handbook Individual Service Plan and Case Assessment.

Request for Good Cause Determination (WTW 27)

A client can request a DA waiver in writing or verbally through their EW or AEC/EC. When requesting in writing, the Sworn Statement (GEN 853) and Request for Good Cause Determination (WTW 27) are two written methods for requesting the waiver/exemption.

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 DA at the time they are identified and at their annual redetermination. 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 DA situation cannot be transferred to the receiving county unless they sign a new WTW 37 form in the receiving county. Refer to Domestic Abuse Cases for more information.

Supporting Documentation

It is not required for the client to provide supporting documentation, such as hospital reports or restraining orders, in order for the CalWORKs SW/DV Advocate to approve an exemption/waiver due to DA.

When a client is able to provide supporting documentation, the documentation will be sent to Imaging.

Supporting documentation of DA may include, but is not limited to:

• A sworn statement by the client
• Forms with check boxes that indicate DA and signed under penalty of perjury
• Police, government agency, or court records or files
• Documentation from a DA program
• Documentation from a legal, clerical, medical, or other professional from whom the applicant or recipient has sought assistance in dealing with DA
• Physical evidence of abuse
• Statement from another individual with knowledge of the circumstances that provide the basis for the claim of abuse
• Any other evidence that supports the statement.

Related Topics

Domestic Abuse

Domestic Abuse Referral Process

Domestic Abuse Good Cause

Program Requirements that Can be Waived

Domestic Abuse Exemption/Extender

Battered Non-citizen Status