Family Services (FS) Correspondence

The following brochure, forms and notices are used to support the Family Services (FS) Program as follows:

SCD 2417

The Family Services Program Request & Application (SCD 2417) is a substitute for the state Family Stabilization Program Evaluation Request (FSP 1) form. The SCD 2417 is provided by CWES and Community Partners and completed by clients to request FS services, including Family Stabilization housing assistance for homeless prevention and CalWORKs Housing support to assist clients who are homeless or being evicted. The form includes a cover sheet describing available services. The form is completed by the client and forwarded to the assigned Associate Employment Counselor (AEC)/Employment Counselor (EC).

W-9

The Request for Taxpayer Identification Number and Certification (W-9) is completed by the landlord. The W-9 is used to issue a 1099 to landlords for income tax purposes. The 1099 is the same form used for child care providers.

SCD 2392

The Family Service Plan (SCD 2392) describes the services that are provided to the client. It contains timelines for achieving goals and is completed as follows:

• When the client agrees on an integrated FS Plan, a Welfare-To-Work Plan Activity Assignment (WTW 2) is also completed.
• When the client agrees on an FS stand-alone plan, only the SCD 2392 is completed.

SCD 2418-A

The Family Services Weekly Employment Plan (SCD 2418-A) is completed by the client to provide weekly status updates on job search goals and objectives. The information on the SCD 2418-A is incorporated into the FS Plan. The form is also used by the FS Employment Connection Center (ECC) AEC/EC to document weekly incentive payments.

SCD 2418-B

The Family Services Weekly Housing Search Plan (SCD 2418-B) is completed by the client to provide weekly status updates on housing search goals and objectives. The information on the SCD 2418-B is incorporated into the FS Plan.

SCD 2416

The Family Stabilization Housing Assistance Referral (SCD 2416) is completed by the FS AEC/EC to refer clients to Family Stabilization Housing Assistance. Parts A and B are completed by the FS AEC/EC to indicate the services approved and is forwarded to the FS Supervisor and/or FS Lead with supporting documents. The FS Supervisor or Social Services Program Manager (SSPM) returns the form to the FS AEC/EC with Part C completed, including outcome information.

SCD 2599-A

The Homelessness Prevention System (HPS) Referral Form (SCD 2599A) is completed by the FS AEC/EC and the Office of Supportive Housing (OSH). It is used to refer a client in need of one-time financial assistance to prevent homelessness to OSH and its service provider Sacred Heart Community Service.

SCD 2599-B

The Homelessness Prevention System (HPS) Authorization to Release & Exchange Confidential Information (SCD 2599B) is completed by the client authorizing the release of their information to OSH and its service provider Sacred Heart Community Service. The authorization is valid for one year from the date of signature unless specified.

SCD 2599-C

The Homelessness Prevention System (HPS) Tips to Prepare for Your Appointment (SCD 2599C) is an informational document detailing the at-risk homelessness verification clients may need to collect.

SCD 2419

The CalWORKs Housing Support Program Service Referral (SCD 2419) is completed by the FS AEC/EC to refer the client to Abode for the CalWORKs Housing Support Program (CHSP). Parts A and B are completed by the FS AEC/EC to indicate the amount to be paid and forwarded to Abode with supporting documents. Abode returns the form to the FS AEC/EC with Part C completed, including enrollment information.

SCD 29

The CalWORKs Referral Results (SCD 29) form is used by Mental Health, Substance Abuse, and Social Work staff to incorporate services into the FS Plan.

Continue using the CalWORKs Domestic Abuse Service Plan (SCD 1555) for Domestic Violence services.

SCD 1554

The CalWORKs Domestic Abuse Participation Status (SCD 1554) includes exemption/waiver information, which is incorporated into the FS Plan.

SCD 1555

The SCD 1555 includes steps/timelines for the service provider’s activities, which are incorporated into the FS Plan.

FSP 2

The Family Stabilization Program Denial (FSP 2) state Notice of Action (NOA) is used to notify clients of the reason for the denial of FS services, including Family Stabilization Housing Assistance.

FSP 3

The Family Stabilization Program Change in Program Status (FSP 3) is a state NOA to notify clients that they are being removed from the FS program due to not having a good reason for not complying with their FS Plan. The NOA includes an appointment section to schedule clients to sign a WTW Plan.

NA 823

The Notice of Action - Ancillary Expenses Approval/Denial (NA 823) is used when approving FS payments, such as At-Risk Youth services and/or Family Stabilization Housing.

• The NA 823 is also used per existing Ancillary procedures. Refer to Ancillary Expenses.
• The NA 823 is not used for FS denials; instead, use the FSP 2.