Form WTW37 "Permission to Release Domestic Abuse Information When Moving to Another County" - California

Form WTW37 or the "Permission To Release Domestic Abuse Information When Moving To Another County" is a form issued by the California Department of Social Services.

The form was last revised in July 1, 2009 and is available for digital filing. Download an up-to-date Form WTW37 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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Download Form WTW37 "Permission to Release Domestic Abuse Information When Moving to Another County" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERMISSION TO RELEASE DOMESTIC ABUSE INFORMATION
WHEN MOVING TO ANOTHER COUNTY
PARTICIPANT’S NAME
CALWORKS CASE NUMBER
CALIFORNIA IDENTIFICATION NUMBER (CIN)
If you move, you may want the new county to know about your domestic abuse waiver or services. This will help the new
county get you the services and welfare-to-work plan you need. This form tells us whether you want to do this.
I understand that:
I do not have to give others information about my domestic abuse situation, but I can volunteer this information
whenever I want.
If I do not sign the release and if I move, __________________ county will not forward any domestic abuse information,
including my waiver, to the new county. I would then need to tell the new county about my domestic abuse if I want to
get services or a waiver.
Everyone in the new county must keep all the information confidential. This means it cannot be given to third parties.
MY CHOICE
___ I agree ______________________________ County Welfare Department can give the following domestic abuse
information if I move to another county:
___ A copy of any domestic abuse waiver
___ Information about my domestic abuse services
___ Other: _____________________________________________________________
.
___ I do not want the following information released:
___ Address
___ Telephone number
___ Employment information
___ My children’s school information
___ Other: ___________________________________________________________
___ I do not want any information released.
Please initial below:
___ I have read this form (or had it read to me) after it was completed and before I signed it.
___ I can cancel this form at any time.
___ My release ends one year from the date I sign this form, or when my domestic abuse waiver ends, if I do not cancel
the form earlier.
Please check one:
___ Yes, I do want a copy of this form at this time.
___ No, I do not want a copy of this form at this time. I can get a copy any time I ask.
PARTICIPANT’S SIGNATURE
TODAY’S DATE
REFUSAL/CANCELLATION OF RELEASE:
I do not want________________________ County to give information about my domestic abuse to a new county if I move.
PARTICIPANT’S SIGNATURE
TODAY’S DATE
WTW 37 (7/09)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERMISSION TO RELEASE DOMESTIC ABUSE INFORMATION
WHEN MOVING TO ANOTHER COUNTY
PARTICIPANT’S NAME
CALWORKS CASE NUMBER
CALIFORNIA IDENTIFICATION NUMBER (CIN)
If you move, you may want the new county to know about your domestic abuse waiver or services. This will help the new
county get you the services and welfare-to-work plan you need. This form tells us whether you want to do this.
I understand that:
I do not have to give others information about my domestic abuse situation, but I can volunteer this information
whenever I want.
If I do not sign the release and if I move, __________________ county will not forward any domestic abuse information,
including my waiver, to the new county. I would then need to tell the new county about my domestic abuse if I want to
get services or a waiver.
Everyone in the new county must keep all the information confidential. This means it cannot be given to third parties.
MY CHOICE
___ I agree ______________________________ County Welfare Department can give the following domestic abuse
information if I move to another county:
___ A copy of any domestic abuse waiver
___ Information about my domestic abuse services
___ Other: _____________________________________________________________
.
___ I do not want the following information released:
___ Address
___ Telephone number
___ Employment information
___ My children’s school information
___ Other: ___________________________________________________________
___ I do not want any information released.
Please initial below:
___ I have read this form (or had it read to me) after it was completed and before I signed it.
___ I can cancel this form at any time.
___ My release ends one year from the date I sign this form, or when my domestic abuse waiver ends, if I do not cancel
the form earlier.
Please check one:
___ Yes, I do want a copy of this form at this time.
___ No, I do not want a copy of this form at this time. I can get a copy any time I ask.
PARTICIPANT’S SIGNATURE
TODAY’S DATE
REFUSAL/CANCELLATION OF RELEASE:
I do not want________________________ County to give information about my domestic abuse to a new county if I move.
PARTICIPANT’S SIGNATURE
TODAY’S DATE
WTW 37 (7/09)
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