Form Cw 2217 Calworks Request For Voluntary Repayment
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALWORKS REQUEST FOR VOLUNTARY REPAYMENT
Case Name _______________________________
Case Number ___________________________
Date of Birth _______________________________ Last 4 digits of SSN ______________________
On _________________, you were told that you were overpaid California Work Opportunity And Responsibility to Kids (CalWORKs)
benefits:
All or part of the CalWORKs payment you got for the month(s) of __________ to __________ is an overpayment. You are getting this
form because all of the following apply:
• You got this form after an explanation by the County of the overpayment; and
• The County did not ask you to make voluntary payments; but, you asked to make voluntary payments.
• You may volunteer to repay all or part of the overpayment. The amount of the overpayment is $_______________________.
You are making a ☐ one-time ☐ monthly (check one) voluntary repayment of $_______________________. Repayment
method:
☐ Check
☐ Cash
☐ EBT. You can stop your voluntary payments at any time. If you decide to stop your voluntary
payments, the county can collect the rest of your overpayment.
If you agree to this voluntary repayment, you may send a check or money order to the address listed below. Please include your case
number on your check or money order. Payments should be mailed to:
County Contact Name:
County Department/District office:
Address:
City, State and Zip Code:
OR
If you want money taken directly out of your EBT account at one time, please enter the amount you would like taken out of your
CalWORKs EBT account and sign and date below .
$_______________
_____________________________________________________
_______________
Amount
Signature
Date
EBT card number: ____________________
Overpayment claim number: ____________________
By signing this form, I understand that I am authorizing the County to deduct funds from my EBT account to repay my overpayment. I
certify that I am the EBT cardholder on this account. I understand that as an EBT cardholder I have the authority to authorize payment
from this account in order to make a payment on an overpayment. I understand that repayment of an overpayment using EBT account
funds is a voluntary action and I am giving my consent to use CalWORKs benefits from this account to repay overpaid benefits. I
understand that this agreement may be altered or terminated at any point in the future at my request. If you have any questions about
how the overpayment was figured or about repayment arrangements, please call:
____________________________________________ at __________________________.
Worker Name
Worker Phone Number
County Only Section
Benefits withdrawn from Cash EBT account for cash overpayment:
Claim: _______________________ in the amount of $______________________.
Worker name: ______________________________________________________
Worker signature: ___________________________________________________
Worker number: _____________________________________________________
Date: ______________________________________________________________
CW 2217 (1/15) REQUIRED FORM-SUBSTITUTES PERMITTED
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