Form CW88 "Diversion Services Agreement -calworks Program" - California

Form CW88 or the "Diversion Services Agreement -calworks Program" is a form issued by the California Department of Social Services.

The form was last revised in June 1, 2011 and is available for digital filing. Download an up-to-date fillable Form CW88 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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Download Form CW88 "Diversion Services Agreement -calworks Program" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DIVERSION SERVICES AGREEMENT
CalWORKs Program
CASE NAME
CASE NUMBER
WORKER NAME
WORKER NUMBER
WORKER COMPLETES:
■ ■
Cash payment in the amount of: $______________________ for the following need: ____________________________
_______________________________________________________________________________________________
■ ■
Non-cash services: The purchase price or current value for the non-cash services is: $______________________
Describe non-cash services: ________________________________________________________________________
■ ■
The diversion period will be from ____________________ to ____________________.
(DATE)
(DATE)
APPLICANT COMPLETES:
I choose to get diversion services because I do not need or want to get cash aid every month, but I need some cash or
non-cash assistance now to solve a current need or emergency situation. The county and I agree to the above method of
payment.
Initial Each Item
______
I certify that I have read the diversion coversheet. I understand the rules and my responsibilities for choosing
diversion services instead of getting cash aid each month.
I also understand that:
______
I will get a notice that denies my current application for cash aid, and gives me the method of payment for my
diversion services and the number of months in my diversion period.
• When figuring the number of months in my diversion period, the county will take the amount of the
payment/services and divide it by the Maximum Aid Payment for my assistance unit at the time I received
diversion services.
• When figuring my diversion period, the county determines the purchase price/current value for the non-cash
services.
______
I will get a separate approval or denial notice(s) for any other benefits I applied for, such as CalFresh
and Medi-Cal.
______
If I apply and am found eligible for cash aid before my diversion period ends, I must tell the county I choose to
either:
• Repay the cash value of the diversion services by lowering my monthly cash aid payment by an amount
determined by the county; or
• Count the number of months in my diversion period toward the 48-month maximum limit on the time I am
eligible to get aid.
______
If I apply for cash aid and am found eligible after my diversion period ends, the county will only count one month
against my 48-month time limit. No repayment is required.
SIGNATURE OF PARENT OR CARETAKER RELATIVE
DATE
SIGNATURE OF ADULT SPOUSE, REGISTERED DOMESTIC PARTNER OR OTHER PARENT (IF LIVING IN THE HOME)
DATE
SIGNATURE OF WITNESS TO MARK OR INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
I certify the parent/caretaker relative has been given a copy of the CW 88 “Coversheet and Diversion Services Agreement.”
The parent/caretaker relative says he/she understands the rules and his/her responsibilities for choosing
diversion services instead of getting monthly cash aid. The parent/caretaker relative also says he/she understands the
rules for the diversion period.
SIGNATURE OF COUNTY WORKER
DATE
COUNTY USE ONLY
Diversion Period Calculation:
Diversion Amount $________ ÷ AU MAP $ ____________ = ____________ months. (Exclude partial months.)
CW 88 (6/11) DIVERSION SERVICES - REQUIRED FORM - SUBSTITUTE PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DIVERSION SERVICES AGREEMENT
CalWORKs Program
CASE NAME
CASE NUMBER
WORKER NAME
WORKER NUMBER
WORKER COMPLETES:
■ ■
Cash payment in the amount of: $______________________ for the following need: ____________________________
_______________________________________________________________________________________________
■ ■
Non-cash services: The purchase price or current value for the non-cash services is: $______________________
Describe non-cash services: ________________________________________________________________________
■ ■
The diversion period will be from ____________________ to ____________________.
(DATE)
(DATE)
APPLICANT COMPLETES:
I choose to get diversion services because I do not need or want to get cash aid every month, but I need some cash or
non-cash assistance now to solve a current need or emergency situation. The county and I agree to the above method of
payment.
Initial Each Item
______
I certify that I have read the diversion coversheet. I understand the rules and my responsibilities for choosing
diversion services instead of getting cash aid each month.
I also understand that:
______
I will get a notice that denies my current application for cash aid, and gives me the method of payment for my
diversion services and the number of months in my diversion period.
• When figuring the number of months in my diversion period, the county will take the amount of the
payment/services and divide it by the Maximum Aid Payment for my assistance unit at the time I received
diversion services.
• When figuring my diversion period, the county determines the purchase price/current value for the non-cash
services.
______
I will get a separate approval or denial notice(s) for any other benefits I applied for, such as CalFresh
and Medi-Cal.
______
If I apply and am found eligible for cash aid before my diversion period ends, I must tell the county I choose to
either:
• Repay the cash value of the diversion services by lowering my monthly cash aid payment by an amount
determined by the county; or
• Count the number of months in my diversion period toward the 48-month maximum limit on the time I am
eligible to get aid.
______
If I apply for cash aid and am found eligible after my diversion period ends, the county will only count one month
against my 48-month time limit. No repayment is required.
SIGNATURE OF PARENT OR CARETAKER RELATIVE
DATE
SIGNATURE OF ADULT SPOUSE, REGISTERED DOMESTIC PARTNER OR OTHER PARENT (IF LIVING IN THE HOME)
DATE
SIGNATURE OF WITNESS TO MARK OR INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
I certify the parent/caretaker relative has been given a copy of the CW 88 “Coversheet and Diversion Services Agreement.”
The parent/caretaker relative says he/she understands the rules and his/her responsibilities for choosing
diversion services instead of getting monthly cash aid. The parent/caretaker relative also says he/she understands the
rules for the diversion period.
SIGNATURE OF COUNTY WORKER
DATE
COUNTY USE ONLY
Diversion Period Calculation:
Diversion Amount $________ ÷ AU MAP $ ____________ = ____________ months. (Exclude partial months.)
CW 88 (6/11) DIVERSION SERVICES - REQUIRED FORM - SUBSTITUTE PERMITTED
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