Form Cw 2190a - Calworks 48-Month Time Limit Extender Request Form
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CalWORKs 48-MONTH TIME LIMIT EXTENDER REQUEST FORM
PLEASE PRINT
YOUR NAME
COUNTY USE ONLY
ADDRESS
STREET
COUNTY
ZIP
CASE NAME
CITY
PHONE
CASE NO.
OTHER ID NO.
(
)
WORKER NAME
QUESTIONS? ASK YOUR WORKER.
Beginning July 1, 2011, most adults cannot get aid for more than a total of 48 months (4 years) from the CalWORKs
program. (This includes aid you got from other states’ Federal Temporary Assistance for Needy Families (Tribal TANF)
Programs on and after January 1998.) However, aid can be paid beyond the CalWORKs 48-month time limit, if you and
all parents, aided stepparents, and/or caretaker relatives in the home meet one of the conditions listed below.
If you answer “Yes” to any of these questions, you may be eligible for an extender. Please answer all the questions. If you
need help with this form contact the county, but the county cannot complete this form for you. Please be sure to sign and
date the back of this form. You may need to send more information to help the county decide if you can be extended on aid.
YES
NO
CalWORKs 48-MONTH TIME LIMIT EXTENDERS
I
I
1. Are you staying at home to take care of someone in the household who cannot take care of
her/himself, which impairs you from working or participating in welfare-to-work activities?
I
I
2. Are you the nonparent caretaker relative of a child who is a dependent or ward of the court in foster
care, or at risk of being placed in foster care?
I
I
3. Are you getting benefits from State Disability Insurance (SDI), Worker’s Compensation Temporary
Disability Insurance (TDI), In-Home Supportive Services (IHSS), or the State Supplemental Program
(SSP) and are you unable to work or to participate in a welfare-to-work activity on a regular basis?
I
I
4. Although you are not getting disability benefits, is a physical or mental problem keeping you from
working or participating in welfare-to-work activities for 20 or more hours per week?
I
I
5. Are you able to work or take part in welfare-to-work activities for 20 or more hours per week even
though you have a physical or mental problem, because you get help with the problem? For example,
you receive counseling, treatment, or special tutoring to enable you to cope with the problem. Otherwise the
problem would keep you from working or participating in welfare-to-work activities.
(The county will review your past and current records to determine if you qualify for this extender. Aid
may be extended if you worked or participated in welfare-to-work in the past.)
CalWORKs 48-MONTH TIME LIMIT EXTENDER FOR ADVANCED AGE - If you are 60 years of age or older, you may
contact your worker to ask for an extender for advanced age. You do not have to complete this form to ask for the
extender.
OTHER AIDED ADULTS IN THE HOME - All other parents, aided stepparents, and/or caretaker relatives in your home
must also qualify for an extender in order for you to be extended on aid. She/he must complete a separate request form.
You can be extended on aid if the other adult(s) is not in your assistance unit and she/he has not received aid for
48 months.
PLEASE READ AND SIGN THE BACK OF THIS FORM.
CW 2190A (4/16) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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