Form Wtw 50 - Program Integrity Request For Regulation Interpretation
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROGRAM INTEGRITY
REQUEST FOR REGULATION INTERPRETATION
INSTRUCTIONS: Complete items 1 -10 of the form. Use a separate form for each policy interpretation request. Retain a copy of the
Word Document for your records, and submit via email to: PIBPolicy@dss.ca.gov.
1.
5.
COUNTY:
REQUESTOR NAME:
2.
6.
SUBJECT:
PHONE NO:
EMAIL:
3.
7.
REFERENCES: (ACLs/ACINs, COURT CASES Etc.)
REGULATION CITE(S):
4.
8.
DATE RESPONSE NEEDED:
DATE OF REQUEST:
9.
QUESTION: (INCLUDE SCENARIO IF NEEDED FOR CLARITY):
REQUESTOR’S PROPOSED ANSWER
10.
:
11.
CDSS RESPONSE:
PROGRAM INTEGRITY ANALYST:
APPROVING MANAGER:
DATE:
DATE:
# (CDSS Use Only):
DATE RESPONSE RECEIVED/LOG
Please note: The policies expressed in this response are based on the unique set of facts presented and should not be presumed to
apply in other situations.
WTW 50 (6/16)
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