Form Temp 2171 - Calworks Self-Initiated Program (Sip) Review Request Form
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CalWORKs SELF-INITIATED PROGRAM (SIP)
REVIEW REQUEST FORM
INSTRUCTIONS: If you believe that any of the situations listed on this form apply to you, please fill out this form and return
it to the county no later than October 29, 1999. If the form is not submitted to the county welfare department by
October 29, 1999, any claim for benefits or restoration will be denied.
Please print or type answers to the following:
NAME
DATE OF BIRTH
ADDRESS
SOCIAL SECURITY #
CASE #
TELEPHONE #
If you were in a school program that you enrolled in on your own (a SIP) when you were required to participate in the
CalWORKs Welfare-to-Work Program and you answer yes to any of the questions below you may be able to:
•
go back to school;
•
get money for books, transportation and childcare;
•
have your sanction overturned and get cash aid;
•
have your welfare-to-work plan changed.
Please answer the following questions about your school program (SIP):
NAME OF COLLEGE/SCHOOL PROGRAM:
ADDRESS OF COLLEGE/SCHOOL PROGRAM:
YES
NO
At any time on or after January 1, 1998, did the county:
1. Refuse
to
make
the
school
program
(SIP)
one
of
your
assigned
CalWORKs
Welfare-to-Work activites?
2. Refuse to allow you to continue in your unapprovable school program (SIP) until the end of the quarter
or semester?
3. Deny, shorten or change your school program (SIP) because it was not full time or could not be com-
pleted within the 18- or 24-month welfare-to-work time period?
4. Require that you take a job that was during your school (SIP) class hours?
5. Refuse to count your work-study hours toward your SIP Welfare-to-Work participation requirement?
6. Refuse to treat elective courses that count toward your degree, or tutorials designed to address your
diagnosed learning disability, as part of your school program (SIP)?
7. Refuse to pay for necessary supportive services while you were in the school program or in work-
study?
8. Deny or reduce your supportive services without your agreement based on your receipt of financial aid?
9. Did you have any other problem with the county regarding your school program (SIP)? If so, what was
it?________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
SIGNATURE OF SIP PARTICIPANT
DATE SIGNED
NOTE: A letter that provides information about SIP policies, can be obtained at the Department’s external web page at:
Select “All County Letters” and go to Letter # 99-32.
TEMP 2171 (9/99)
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