6. Application Process

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1 General Assistance Handbook page Applications, Reapplications, Home Visits and Beginning Date of Aid GA Policies GA Policy [104] - Application An applicant shall submit to the Department an application for aid and a statement of facts; and verify the information provided therein, the application and statement of facts to be in a form prescribed by the Department. GA Policy [109] - Timeliness of Eligibility Determination The Department shall make a determination of eligibility within 45 days of receipt of a proper application. GA Policy [140] - Residence Applicants and recipients MUST be residents of the State of California and the County of Santa Clara. Residence requires at least fifteen (15) days of continuous physical presence and the intent to remain indefinitely within the State of California and the County of Santa Clara. Residence must be supported by subjective proof. The method of such proof shall be devised by the Agency. [Refer to Residence/Emergency Shelters, page 17-1for process]. GA Policy [271] - Initial Payment of Aid The initial payment of aid shall be effective on the date of determination of eligibility, or on the tenth (10th) day following the date of filing of a signed application, whichever is earlier. For a sanctioned case, if the date of filing is ten (10) or more days prior to the end of the sanction period, the effective date shall be the first day following the end of the sanction period. For new residents of Santa Clara County, as defined in GA 140, aid shall be effective no earlier than the sixteenth (16th) day following the date of continuous physical presence in the County of Santa Clara. Update # Revised: 04/15/16

2 page 6-2 General Assistance Handbook GA Policy [274] - Emergency Support Payment Pending Eligibility Determination The Department may make an emergency support payment pending a determination of eligibility, the amount not to exceed 25 per cent of the maximum monthly aid payment to which the person or persons are entitled. [Refer to GA Handbook Chapter 27, Section Presumptive Eligibility, page 27-2]. 6.2 The following are policy and procedures related to the application process: Date of Filing The date of filing is the date on which the applicant submits a signed Application for General Assistance (GA 1) and an Identification and Intake Record (SCD 41). The Customer Service Technician (CST)/EW must place a check in the County Use Only section of the GA 1 and enter the date that a copy of the completed GA1 was given to the applicant Beginning Date of Aid The beginning date of aid is the first date on which General Assistance becomes effective. Benefits for all GA applicants shall be effective on the earliest of: The date of determination of eligibility; OR The tenth day following the date of filing a signed application. Example: Joe Smith completes an SCD 41 and a GA 1 on July 7. He sees an Intake EW on July 9, and clears eligibility on July 15. The beginning date of aid is July 15 (the date of eligibility determination). Example: Mary Brown completes an SCD 41 and a GA 1 on July 7, but doesn't see an Intake EW until August 12. She clears eligibility on August 25. The beginning date of aid is July 17 (the tenth day following the date of filing a signed application). Revised: 04/15/16 Update #

3 General Assistance Handbook page Failed or Reshceduled Appointments GA applications shall be denied if clients fail to attend their scheduled interview appointment. Clients may request to change their interview appointment and a new appointment date may be given within 45 days from the date of application. The application shall be processed using the original application date Recording of Applications All GA applications shall be recorded as pending within one (1) working day after the completion of a signed Application for General Assistance (GA1) Applicant on Sanction An application taken on an applicant who is currently on a sanction must be approved or denied per office policy Beginning Date of Aid Sanction Ends If a sanction is imposed and a reapplication is filed fifteen (15) days less before the end of the sanction period, the application shall be processed before the end of the sanction period, so that the effective date of GA will be the first day following the end of the sanction period. If a sanction is imposed and a reapplication is filed more than fifteen (15) days before the end of the sanction period, the application will be denied. Note: At no time shall GA become effective before the end of the sanction period Failure to File an Appeal/GA Discontinuance GA benefits will be discontinued if the recipient (or the SSI Advocacy Unit on be half of the client) fails to file either a timely: Appeal with the Social Security Administration, or Waiver (based on good cause) of the time limit. Update # Revised: 04/15/16

4 page 6-4 General Assistance Handbook The client will remain ineligible until cooperation is achieved with all aspects of the SSI application process, including all necessary medical examinations. GA may not be denied/discontinued for the above reason unless it can be proven that the client was aware of their responsibility to file an appeal. The client's signature on the General Assistance Program- Rights and Responsibilities (GA 14) form is sufficient evidence that the recipient understood his/her responsibilities. The only time that the SSI Advocacy Social Worker would not file an appeal is when he/she: Receives notification of a denial too late to file an appeal within the required time limit, or Determines the appeal to be inappropriate Adding Spouse to the Program If the spouse of a currently active recipient of GA makes a request for aid, the application will follow the normal intake process Face-to-Face Interview Requirements A face-to face interview with the applicant is required PRIOR to granting aid. Married couples living together are required to apply together, be interviewed together and sign the application and other documents together. Both must sign the General Assistance Program - Rights and Responsibilities (GA 14) and Statement of Facts (SOF) Home Visit Definition An applicant who declares an inability to come to the General Assistance office for an initial interview, must be evaluated for a home visit. Note: This includes inpatients at Santa Clara Valley Medical Center (VMC). Revised: 04/15/16 Update #

5 General Assistance Handbook page Home Visit Referrals Applicants requesting a home visit, should be advised to call GA District Office main number. The referral process is as follow STEP Designated Clerical Staff ACTION Completes an Identification and Intake Record (SCD 41) with the following information: Completes the ID processes in CalWIN by clicking on the [Individual Inquiry] button in the Inquiry Function box. Completes the Home Visit Request (GA 66). Submit the completed GA 66 to the Information Supervisor. Information Supervisor The EW Supervisor will maintain a control of all incoming approved or denied home visit requests. Reviews Home Visit Request form. If the home visit request is approved, the screening EW Supervisor will complete the SCD 41. Makes a TMT Request for case assignment to an Intake EW for processing. Forwards the SCD 41 and the GA 66 to the designated clerical staff. If a home visit is deemed inappropriate, the screening EW Supervisor will inform and advise the applicant of the regular application process. If the request is denied, the Supervisor will advise the applicant of the regular application process. Clerical Completes Application Registration and assigns to EW. Update # Revised: 04/15/16

6 page 6-6 General Assistance Handbook STEP Intake EW ACTION Receives a folder with paper application packet Contacts SWS/Lead to coordinate joint Home Visit with a Social Worker worker Conducts Intake Interview with applicant. Issues Authorization for Use and Disclosure of Protect Health Information Pursuant to HIPAA (SCD 1400 A) and General Assistance Program - Request for Medical Information (SCD 1400) and obtains applicants signature, unless other acceptable verification is provided. Completes and obtains applicants signatures on forms Referral to/from Social Security (SCD 169) and Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment (SSP 14) must be scanned into IDM and the SCD 169 must be completed by Social Security Administration. Ensures that client s unemployability information is entered into CalWIN on the Collect Employability Detail window and runs EDBC. Social Worker Completes the General Assistance Cooperation Agreement For Unemployable Applicants And Recipients (SCD 523 U) and obtains clients signature. Returns the completed SCD 523 U to Intake EW. Requests the CST to enter case assignment into CalWIN and SSI Tracking System Withdrawal of Application Applicants who decide to withdraw their applications shall be requested to complete a Withdrawal of Application (SCD 166). If the EW is unable to obtain a completed SCD 166 from the applicant, the EW shall document in CalWIN Maintain Case Comments window the reason for the withdrawal request and why the SCD 166 was not signed by the applicant. Revised: 04/15/16 Update #

7 General Assistance Handbook page Reapplications IF AN INTAKE EW: Denies an application and the applicant subsequently reapplies within the same month, Is unable to take the reapplication, Discontinues a recipient from aid and the recipient subsequently reapplies, THEN: The applicant shall be referred to the same Intake EW, if possible. The applicant shall be referred through the normal intake process. The Intake EW shall be responsible for the case until the effective date of discontinuance. 6.3 Eligibility Procedures The following are procedures to be considered when making an eligibility determination: CalWORKs Eligibility At the point of intake or any time circumstances change where an applicant/ recipient could be considered a parent or child and would meet CalWORKs eligibility, the applicant/recipient must be referred to an Intake District Office to make an application for CalWORKs. If the applicant/recipient is eligible to receive CalWORKs, there is no eligibility for General Assistance, send NOA Eligible to Apply for CalWORKs (GA 231). Note: The GA applicant must have physical custody of the child(ren) at the time of application. Parents of SSI children applying for GA, must be referred to CalWORKs, they are NOT eligible for GA. Pregnant women age 19 or older in their second trimester of pregnancy may be eligible for CalWORKS. They must be referred to an Intake District Office to make an application for CalWORKS. Update # Revised: 04/15/16

8 page 6-8 General Assistance Handbook Pregnant teens age 18 or younger, with no other eligible children in the home, may be eligible for CalWORKs cash aid and PSN upon verification of pregnancy. An applicant/recipient who is ineligible for a federal or state cash program shall be treated as follows: Sanction/Penalty - An applicant/recipient who is receiving CalWORKs on behalf of an eligible child, but who is denied/discontinued from CalWORKs due to a sanction/penalty is not eligible for General Assistance for the duration of the sanction period(s), send CalWIN NOA Period of Ineligibility for CalWORKs/SSI/RCA (GA 115). [Refer to W & I Code (b)] Lump Sum Income - An applicant/recipient who is ineligible for CalWORKs or SSI due to the receipt of lump sum income, is not eligible for General Assistance for the duration of the ineligibility period. Felony - An applicant/recipient who is ineligible CalWORKs due to a felony is not eligible to receive General Assistance until all children for whom they received CalWORKs have reached age 18, whether or not the children are living in their home. [Refer to CalWORKs Chapter 25, Section 25.7 Drug Felon, page 25-15]. 48-Month Time Limit (or TANF TOA) - CalWORKs recipients who is not eligibility for CalWORKs as a result of the 48-month time limit (or TANF TOA) are NOT eligible to receive General Assistance until all children for whom they received CalWORKs reach age 18, whether or not the children are living in their home. [Refer to W & I Code 17021(a) and CalWORKs Chapter 39, Section 39.1 Overview, page 39-1]. Zero Basic Grant - An applicant/recipient who is ineligible CalWORKs or SSI who have a zero basic grant due to a penalty, or the grant is less than $10, or reduced to a zero grant after an O/P adjustment is not eligible to receive General Assistance. CalWIN does not have a specific General Assistance denial Notice Of Action for the reasons listed above, therefore, NOA General Assistance Program Notice of Action and/or Proposed Action (GA 239) must be used for this purpose. The GA 239 is available online in the Agency s Intranet, under DEBS forms. [Refer to GA Handbook Chapter 1, Section 1.42 GA 203 Ineligibility for Federal / State Program, page 1-14.] Revised: 04/15/16 Update #

9 General Assistance Handbook page Age Requirement All applicants/recipients must be 18 to 64 years of age. If 65 or older, the applicant must be pending SSI or ineligible for SSI. If 62 or older, the applicant must apply for Social Security benefits (RSDI) and be ineligible for these benefits. Age shall be verified by birth certificate or other identification, such as driver's license, Department of Motor Vehicles (DMV) Identification (ID), baptismal certificates, school records, or other documentation. Unmarried minors under 18 years of age are not GA eligible. Unmarried is defined as never married or marriage annulled. Persons who are married, divorced or legally separated are not considered minors. Legal marriage and/or divorce or dissolution shall be verified by documentary evidence prior to granting aid; i.e., marriage/divorce certificate or court order Sheriff s Department Public Service Program (PSP) Participants in the Sheriff's Department's Public Service Program (PSP) are ineligible for General Assistance. Although PSP participants are not inmates (do not reside in the jail), they are unable to clear eligibility because they are not available to accept ANY bona fide offer of employment (GA policy 215). GA applicants/recipients participating in the PSP who are inmates will continue, for eligibility purposes, to be considered in jail, and will be denied Jail Inmates GA applicants/recipients who are jail inmates and are also in a medical institution are not eligible for General Assistance. Daniel Denial NOA GA 113 or Discontinuance NOA GA 044 Residing in Public Private institution/facility needs to be sent Convicted Fleeing Felons California Welfare and Institutions Code (WIC), Section for General Assistance reads as follows: (a) An individual shall NOT be eligible for aid under this part if he or she is ether: Update # Revised: 04/15/16

10 page 6-10 General Assistance Handbook (1) Fleeing to avoid prosecution, or custody and confinement after conviction, under the laws of the place from which the individual is fleeing, for a crime or an attempted to commit a crime that is a felony under the laws of the place from which the individual is fleeing, or which, in the case of the state of New Jersey, is a high misdemeanor under the laws of that state. (2) Violating a condition of probation or parole imposed under federal law or the law of any state. (b) Subdivision (a) shall not apply with respect to conduct of an individual for any month beginning after the President of the United States grants a pardon with respect to the conduct. Due to the law that is outlined in WIC 17016, General Assistance will not be granted to Fleeing Felons Convicted Drug Felons California Welfare and Institutions Code (WIC), Section for General Assistance reads as follows: Every county and every city and county shall relieve and support all incompetent, poor, indigent persons, and those incapacitated by age, disease, or accident, lawfully resident therein, when such persons are not supported and relieved by their relatives or friends, by their own means, or by state hospitals or other state or private institutions. Due to the law that is outlined in WIC 17000, the county must provide aid to Convicted Drug Felons provided the individual: Has not been denied/discontinued from CalWORKS for this reason. [Refer to Felony - An applicant/recipient who is ineligible CalWORKs due to a felony is not eligible to receive General Assistance until all children for whom they received CalWORKs have reached age 18, whether or not the children are living in their home. [Refer to CalWORKs Chapter 25, Section 25.7 Drug Felon, page 25-15]., page 6-8]. Is not fleeing to avoid prosecution, custody or confinement after conviction, as indicated in WIC Revised: 04/15/16 Update #

11 General Assistance Handbook page 6-11 Exception: An applicant/recipient who is ineligible for CalWORKs due to a felony is not eligible to receive General Assistance until all children for whom they received CalWORKs have reached age 18, whether or not the children are living in their home. [Refer to CalWORKs Chapter 25, Section 25.7 Drug Felon, page 25-15] Triage To ensure that the Triage process of reviewing and identifying the need of an applicant is accomplished rather than just providing information the Triage Review Sheet (GA 19) form is used. The Triage process is found in the GA Business Process with detailed information to ensure that applicants appropriately receive CalFresh Expedited Services (CF ES) within the allotted time frames per Federal and State regulations. [Refer to GA Business Process Triage Review, Page - 6.] 6.4 Employment/Termination of Employment The following are employment related definitions: Full-time Employment Persons who are fully employed are not eligible for General Assistance, regardless of the amount of money earned during the month. Fully employed persons include those persons working or in paid training and unavailable for full-time employment Self-employed Self-employed persons (e.g., salesmen, musicians, entertainers, handicraft workers) are considered fully employed, regardless of the number of hours worked. Which means, if they work only one or two hours in a day, in a week, in a month they are still considered fully employed. If income is less than the GA Maximum Basic Need Rate, the self-employed applicant may be eligible for GA, if they terminate that type of work and are available to meet all other program requirements. The applicant must provide a sworn statement that she/he intends to terminate such efforts and to report any Update # Revised: 04/15/16

12 page 6-12 General Assistance Handbook subsequent income. Which means, if their income is less than GA Maximum Basic Need Rate to meet one of the eligibility factors they have to terminate that type of work, be available for employment and fulfill all the Vocational Services job requirements. Client signs a General Affidavit (SCD 101) that he/she intends to terminate such efforts (or Self employment). No sanction shall be applied for termination of self-employment Temporary Employment Temporary employment on a regular basis does not make a person fully employed. If the income is less than the GA Maximum Basic Need Rate, the applicant may terminate such employment, unless it does not interfere with applicable program requirements. No sanction shall be applied for termination of temporary employment. If temporary employment is to continue, the income must be anticipated each month Temporary Layoff Temporary layoff from a regular full-time job because of bad weather does not terminate full-time employment. The person remains fully employed and, therefore, not eligible for GA. Exceptions may be approved by the GA Program Manager Strikers Strikers are considered fully employed (as are those who refuse to cross picket lines in support of a strike) unless the strike has been found to be a violation of an applicable Health and Safety law or there is a lockout on the part of the employer. Strikers include individuals and family members. Revised: 04/15/16 Update #

13 General Assistance Handbook page Contract Employees Contract employees are persons who are paid an annual salary to provide services which render them without employment at various intervals in the year. They are not eligible to receive GA benefits. These persons may include, but are not limited to, teachers, farm contractors, consultants Involuntary Termination If the applicant was involuntarily terminated from employment within 6 months prior to application, the Intake EW shall send an SCD 549 to the former employer. If the termination was within 30 days of the application, action on the application must be withheld for at least 10 working days pending the return of the SCD 549 from the former employer. The applicant shall not be referred to Vocational Services until all eligibility factors have been cleared Voluntary Termination An applicant who voluntarily terminates employment without good cause shall be ineligible for aid for 30 days from the date of termination. Persons who cause their own termination for cause will be deemed to have voluntarily quit their job. EWs are responsible for determining if an applicant/recipient had good cause for voluntarily terminating employment. [Refer to Voluntary Termination of Employment - GA Policy [217], page 30-5 in the GA Handbook.] for specific information. 6.5 Mandatory Forms The following are mandatory and common to all GA applications: 1. GA 1, Application for General Assistance 2. GA 14, General Assistance Program- Rights and Responsibilities 3. GA 100, Statement of Facts for General Assistance, and 4. CSF 60 CalWIN Statement of Facts or Application for CalFresh, Cash Aid and/or Medi-Cal/Health Care Programs (SAWS 2 Plus) Update # Revised: 04/15/16

14 page SCD 41, Identification and Intake Record General Assistance Handbook 6. SCD 355 S/A Agreement to Reimburse - Sponsor (For Sponsors) 7. SSP 14, Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment. Note: To apply for GA in combination with other programs such as CalFresh and/or Medi-Cal, the form Application for CalFresh, Cash Aid and/or Medi-Cal/Health Care Programs (SAWS 2 Plus) can be completed, instead of the GA 100. Reminder: The GA 100 is used simultaneously with CalWIN CSF 60 because the CAlWIN CSF 60 does not have all questions needed for GA. Other mandatory forms which specifically pertain to the type of GA application that is being process; i.e., paper application, employable, unemployable, residences in institutions, etc. must be completed. Refer to the specific section of the handbook. Refer to Common-Place Handbook Chapter 27 [ Intake/RRR Packets, page 24-1] for the required RRR forms: CalFresh RRR Packet, Section 24.5, Medi-Cal RRR Packet, Section 24.6 and GA RRR Packet, Section GA 1 - Application For General Assistance All General Assistance applicants, must complete and sign an Application For General Assistance (GA 1). The GA applicant, and if applicable the applicant's Authorized Representative (AR), or the applicant's Conservator shall complete a GA 1, in duplicate. The applicant's representative may sign the application (GA 1) only if the applicant is physically unable to sign. The applicant's conservator must sign the GA 1. An applicant who is unable to sign his/her name shall be assisted to sign with an X or other mark. The X must be formally witnessed by two persons (this may include the AR and EW). Revised: 04/15/16 Update #

15 General Assistance Handbook page The Statement of Facts Requirements General The CSF 60 CalWIN Statement of Facts or Application for CalFresh, Cash Aid and/or Medi-Cal/Health Care Programs (SAWS 2 Plus) must be signed by the applicant to determine eligibility for General Assistance Rules The Statement of Facts must be signed in ink. It must be signed in the presence of the EW. When both spouses are in the home, each must sign and date the SOF in the presence of an EW, even if one is an excluded person for GA. A signature page, with the applicant/recipient s original signature, must be scanned into the Intergraged Document Management (IDM) System The SOF may be completed with the assistance of another person; however, this person must also sign the SOF. A new SOF is required in All of the following circumstances: Applications. Restorations. Reinvestigations. 6.7 Rights & Responsibilities Explanation The EW must explain the General Assistance Program rights and responsibilities to the client and complete the following: Provides the client with a copy of the General Assistance Program - Rights and Responsibilities (GA 14). Update # Revised: 04/15/16

16 page 6-16 General Assistance Handbook Advises the client that all changes in circumstances and income must be reported within ten days of occurrence and reported on the Quarterly Eligibility/Status Report (QR 7). Provides the client with a Quarterly Eligibility/Status Report (QR 7) and the Instructions & Penalties Quarterly Eligibility/Status Report (QR & addendum), and the form QR 7A How to Fill Out Your QR 7". 6.8 Interview Requirements for Guardian/ Conservators and Authorized Representatives The following are interview requirements for Guardian/Conservators and Authorized Representatives: Guardian/Conservators The court names the Public Guardian as the guardian or conservator of persons. Conservatorship is established by the Court to protect the welfare and interests of persons determined to be incompetent to handle their own affairs. A person may be placed under the conservatorship of the Public Administrator/Guardian/ Conservator (PAGC) if there is no one else available to accept that responsibility. Persons who are conserved are not legally responsible for their own affairs and are therefore unable to apply for General Assistance (GA) on their own behalf. 1. Only PONY correspondence is to be sent to: The Santa Clara County Public Administrator/Guardian/Conservator (PAGC) office 333 W. Julian St San Jose, Ca Phone (408) All U.S. mail for PAGC conserved clients must be sent to: P.O. Box 760, San Jose, CA All GA applications and cases for persons conserved by the PAGC s office will be handled by the GA office. Standard intake procedures and established eligibility criteria must be followed. Revised: 04/15/16 Update #

17 General Assistance Handbook page 6-17 A conservator must ALWAYS accompany the client into the interview. They are empowered to act for the client and to complete and sign the Statement of Facts. If the client is conserved as to finance/estate, the interview MUST be conducted with the conservator and the conservator MUST complete and sign all GA forms. A copy of the court appointment papers must be obtained and sent to IDM for scanning. Forms: Since the intake packet of forms change to comply with regulations and program changes, please refer to the Common Place Handbook for a complete list of required forms. [Refer to Common-Place Handbook, General Assistance (GA), page ] The on-line form Responsibilities of Public Guardian/Conservators or Applicant/Beneficiary Representative (DHCS 7068) for persons applying for combined GA and Medi-Cal programs must be completed and signed by the Public Guardian/Conservator The Eligibility Worker/Public Guardian Communications Form (SCD 1294) is to be used by both the EW, Public Guardian and Conservators to communicate via regarding but is not limited to, requesting information or verifications and reporting changes (e.g., change of address, dismissal of conservatorship, death of client). [Refer to GA Handbook Chapter 13 - Guardian/Conservatorship, page 13-1 procedures and CalWIN Announcement CA-271 process for PAGC cases.] Authorized Representatives The EW must make a private, personal assessment of the client's ability to participate in the interview process. The individual must be capable of participating, understanding and complying with GA requirements. The Authorized Representative (AR) is NOT the legal representative for the client. Therefore, they CANNOT sign documents nor ACT for the client. The AR may only assist the client. For instance, assistance may be required in obtaining verifications. Update # Revised: 04/15/16

18 page 6-18 General Assistance Handbook 6.9 Informing Requirements The EW is responsible for informing the applicant, authorized representative/ conservator of their rights and responsibilities and discussing ALL of the following (as appropriate): The EW must inform the applicant of the categories of aid for which the applicant may apply. (The individual may apply for any type of public assistance.) The county and applicant's responsibility for exploring all facts concerning eligibility, needs and income and the applicant's responsibility for presenting or obtaining records or documents to support his/her statements. Note: If monthly household expenses exceed the anticipated monthly income, the EW shall require the applicant to explain how the expenses will be paid. THIS EXPLANATION SHALL BE DOCUMENTED in CalWIN Maintain Case Comments window. The applicant's responsibility to apply for and take all appropriate steps to obtain specific benefits for which she/he appears to be potentially eligible including, but not limited to: UIB, DIB, VA, OASDI, CAPI, SSA. Explaining the Applicant s rights and responsibilities QR 7 reporting The responsibilities for reporting all facts and for notifying the EW immediately of all changes. The confidential nature of all information. Evidence which may be needed to establish eligibility. The purpose and provisions of the Agency and the available resources within the Agency. The right to request a Fair Hearing. That furnishing a Social Security Card is a condition of eligibility. If the applicant does not have a card, she/he must apply for a duplicate. Revised: 04/15/16 Update #

19 General Assistance Handbook page Immediate Need The EW will be responsible for making immediate need determinations whenever the client claims to be in immediate need Required Signatures The GA applicant, and if applicable the applicant's Authorized Representative (AR), or the applicant's Conservator shall complete and sign a GA 1, in duplicate. The applicant's representative/conservator may sign the application, GA 1 only if the applicant is physically unable to sign. The AR may not sign the Statement of Facts (SOF) except as the person completing the Statement of Facts, if applicable. An applicant who is unable to sign his/her name shall be assisted to sign with an X or other mark. The X must be formally witnessed by two persons (this may include the AR and EW) Sponsors Reimbursement Agreement (R/A) (SCD 355 S/A) All applicants, spouses (if residing with the spouse), and legal guardians applying and/or receiving GA benefits, and who have been sponsored into the United States must have their sponsors sign an R/A in black ink prior to receipt of aid. The R/A is recorded with the County Recorder and is intended to ensure repayment of aid. The R/A creates a lien against all current and future real property for which the signer or co-signer of the R/A holds title in Santa Clara County. Update # Revised: 04/15/16

20 page 6-20 General Assistance Handbook The SCD 355 S/A is public Record and in order for those to obtain this public record it must be completed in English. This is per California Law, Government Code [Refer to Therefore, the County Recorder s office will only accept a signed English SCD 355 S/A document. If other persons have an interest in the real property, the worker must make every effort to obtain their signature(s) on the RA. This activity shall be clearly documented in CalWIN Maintain Case Comments window. Note: If the sponsor(s) has property in a county other than Santa Clara, an R/A must be filed in the other county to create a lien on that property. Follow normal filing procedures. Recovery & Legal, Collections Section will do the processing with the other county Requirement for a New R/A A new R/A is required under ALL of the following circumstances: The signer acquires real property. The signer has changed marital status. The signer has changed their legal name or Social Security number. The previous R/A has been released by the Collections Unit and a copy of the Release Memo is in IDM. Note: Collections scans the Release Memo and/or the Demand Letter into their department s section of Intergraged Document Management (IDM) System; therefore, when applicable, it is necessary to verify with Collections that the Release Memo and/or Demand letter was sent after the case was last closed. Reminder: The EW must check for the last signed R/A in IDM. If one of the changes listed above has occurred, a new R/A must be completed, signed and sent to be recorded with the County Recorders office. The SCD 355 S/A must be photocopied and sent to the different parties involved. Upon completing the SCD 355 S/A form it must be stamped with the GA District Office address on the top left side of the form, where it reads: When recorded, return to:. When the SCD 355 S/A is returned, a copy with the recorded County Record s seal is sent to the client and a copy MUST be scanned into IDM for processing. Revised: 04/15/16 Update #

21 General Assistance Handbook page 6-21 If there is a Recorded copy of the R/A in IDM or, if one has been sent for recording within the previous six months, a new R/A is not required, provided that none of the circumstances listed above have occurred. An alert or a reminder shall be completed for the sixth (6th) month to monitor the return of the recorded reimbursement agreement. Note: At the end of the sixth (6th) month the EW must check to ensure that IDM contains an R/A for a transpired change in circumstance listed above. If the R/A is in IDM and does not meet the occurred change, a new R/A must be completed, signed and sent to be recorded with the County Recorder Completion of the R/A The R/A must be completed in BLACK INK in Triplicate. If Aid Is Denied: Write the words GA Denied over the signed R/A and send to IDM for scanning into permanent verifications folder. DO NOT SEND TO COLLECTIONS. If Aid Is Granted: Send the original English version of the R/A to the County Recorder s office. Send a copy to IDM for scanning into the Permanent Verifications folder and a copy is given to the applicant. All names ever used by the client shall be listed on the top of the document in the space marked Alias and listed on the Collect Individual Aliases Detail window in CalWIN. The signature(s) must match either the name at the top of the R/A or one of the alias names listed at the top. If the middle initial is used in the signature, the name as signed must be listed in the top section of the form as a name the client is known by. The EW must print or type in date, applicant's case number, name, last four digits of the Social Security Number, marital status, maiden name if applicable, birthdate and present address. If there are any aliases which involve a different last name, list them. If the alias is a previous married name or maiden name, so indicate. If there is any real property, complete that section. The EW must obtain the applicant's signature on the first line of the R/A. When applicants are married and not separated, obtain both signatures. Update # Revised: 04/15/16

22 page 6-22 General Assistance Handbook When there is a legal guardian involved, the guardian of the Estate must also sign the R/A. The proper signature for the Public Guardian is: ", Deputy Public Guardian, for Don Moody, (name of deputy) Public Guardian, as conservator of the estate of." (name of client as shown on court papers) Note: The name of the client as shown on the court papers must match the name shown at the top of the document. If it does not match exactly, the name on the court documents must be listed at the top of the R/A as an alias. For names written in picture languages, the client should be encouraged to write the name in English. In most of these cases, a translator will assist the client in the execution of the written English translation as it appears at the top of the document. One of the names on the upper portion and the Deputy Clerk Acknowledgment section below must agree with the exact signature of the R/A grantor(s). R/A's signed with an X require three witnesses to the signature. When it is possible to get the signature of a co-owner of property, that person shall sign the third line on the R/A. The EW must complete the bottom section of the R/A, ensures the name of the current County Clerk name is correct (currently, Regina M. Alcomendras) and signs on the line as Deputy County Clerk. Reminder: The name used when the EW is hired and deputized (only those assigned to GA are deputized, others hired are sworn in) is to be used when signing the bottom section of the SDC 355 S/A. When the Demand Letter for GA repayment from Recovery and Legal/Collections is received for collection or to pay back the GA grant, the Recorder s office compares the signature on the SCD 355 S/A with the signature in their files. For the R/A to be acceptable as a legal document, the person signing as Deputy County Clerk must be deputized by the County. Not to be confused with being sworn in. Revised: 04/15/16 Update #

23 General Assistance Handbook page Sponsor Unable to Complete the R/A In situations when a sponsor(s) is unable, because of physical or mental disability, to sign his own signature on the R/A, the spouse and legal guardian may sign for sponsor. The R/A shall then be completed as follows: The top portion and the property description shall be completed the same as a regular R/A. On the first signature line, the spouse shall sign his/her name. The person signing for the sponsor shall complete the second signature line as follows: Enter the sponsor s name. Enter by and sign his/her own name. Enter Attorney, Guardian, or Conservator, if applicable Routing and IDM Instructions Routing: The original English version of the SCD 355 S/A is sent to the County Recorder s office, a copy is given to the client and/or Public Guardian/Conservator and a copy is sent to IDM for scanning. Ensure that a request is given to the IDM designated clerical staff to discard the IDM copy AFTER receipt of the original Recorded and stamped with the County Seal. AFTER receipt of the original Record/Sealed copy of the SCD 355 S/A, ensure it is scanned into IDM in Permanent Verification. Note: A copy of the Recorded and stamped with the County Seal SCD 355 S/A can be given to the client or Public Guardian/Conservator upon request. IDM: Update # Revised: 04/15/16

24 page 6-24 General Assistance Handbook A copy of the unrecorded SCD 355 S/A is to be sent to IDM for scanning into the Permanent Verification folder (as proof that the R/A was completed). When the R/A has been recorded/sealed, it will be returned to the EW or the designated staff. The County Recorders office stamps the SCD 355 S/A with the County Seal and it will indicate the date the R/A was recorded at the County Recorder's office and the book and the page at the Recorder's office where that record can be found. Upon receipt of the original Recorded/Sealed copy of the R/A, the IDM copy of the R/A is deleted from IDM by the designated clerical staff and the original Recorded /Sealed copy is scanned into in the permanent verification section of IDM. Reminder: The EW must request from designated clerical staff performing IDM duties to delete the unrecorded copy of the SCD 355 S/A Consent to Release Public Assistance Information for Health Services Reimbursement SCD 2263 The SCD 2263 is to give Social Services authorization to provide SCVHHS the needed information for them to pursue Medi-Cal reimbursement if and when the applicant/recipient is made eligible. All GA applicants who receive medical services from Santa Clara Valley Health and Hospital Systems (SCVHHS) must sign the SCD 2263 during the initial interview and at every redetermination. Eligibility staff is to provide and discuss the SCD 2263 with GA clients at the time of Intake and at every Redetermination (RRR). Failure of the applicant or recipient to return the signed SCD 2263 is not a reason for denial or discontinuance. [Refer to Program Directive ] Revised: 04/15/16 Update #

25 General Assistance Handbook page Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment (SSP 14) The SSP 14 must be obtained for persons required to go to Social Security Administration to apply for SSI/SSP. The SSP 14 is required for both GA and CAPI Interim Assistance cases to obtain reimbursement when the client is approved SSI/SSP. Process for the SSP 14: Obtained at Intake (when obtaining the Referral to/from Social Security [SCD 169]) for all unemployable applicants required to apply for SSI. Completes and explain the SSP 14 to the applicant and both applicant and EW (EW signs in the STATE REPRESENTATIVE section) must sign the form. Sends the SSP 14 to be scanned into IDM. Completes the SSI/SSP tab in the Display Individual Demographics Summary window Documents information into CalWIN Maintain Case Comments window. [Refer to GA Handbook Chapter 33, Section Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment (SSP 14), page 33-4.] Note: A copy of the signed SSP 14 MUST be in IDM. Without a copy of the SSP 14 the County cannot recoup the IAR Responsible Relatives The financial responsibility of relatives of GA applicants/recipients shall be limited solely to married couples; that is, spouse-for-spouse responsibility. Update # Revised: 04/15/16

26 page Married Couples General Assistance Handbook Married couples shall be defined as a man and woman or two individuals of the same sex who are lawfully married and living together in the same home. The statement of the couple that they are legally married shall be accepted and no further verification is required. Both members of a married couple shall apply and cooperate with all eligibility requirements or both shall be ineligible. If one member of a couple (or a family) fails to cooperate with VS, the period of ineligibility shall apply to both members, if both able to work (or to the family).[refer to Sanctions for Married Couples, page 30-22]. If a couple or family separate after discontinuance due to noncooperation, aid shall not be granted if there are reasons to believe that the separation was to qualify for aid, a greater amount of aid or avoid the application of a period of ineligibility. The case record should indicate when the couple separated and why the separated spouse cannot reasonably be expected to return. If the worker is satisfied that the separation was not due to one of the above, aid may be granted to the person not responsible for the noncooperation. Married couples living together shall be aided on a single case. Both spouses shall be required to apply together and to sign the application and other documents. All income and property of both spouses shall be included in the eligibility determination Separated Spouses An applicant who is legally married but separated from his or her spouse shall have no financial responsibility for the separated spouse. The applicant shall be required to sign a sworn statement that they are not living together. Examples of separation may include voluntary separation (e.g., legal separation, voluntarily living apart, etc.) or involuntary separation (e.g., spouse in board and care, hospital, jail, etc.) Common-Law Marriage California does not recognize common-law marriages entered into within this state. However, such marriages shall be recognized as valid marriages if: 1. It was entered into in a state which recognizes such marriages, and 2. All conditions were met so as to satisfy that state's criteria for recognition. Revised: 04/15/16 Update #

27 General Assistance Handbook page Unmarried, Childless Couples A man and a woman or two individuals of the same sex who are living together as husband and wife or as a married couple but are not legally married to each other, and who have no children living in that home shall not be considered as a couple for General Assistance purposes. They shall be considered as two individuals in shared housing; their eligibility shall be determined separately, and aid shall be established in their own separate cases Special Situations The following are special situations to be considered: SSI/SSP Spouse If a spouse receives SSI/SSP or other public assistance, that spouse shall not be financially responsible for the GA applicant spouse, nor shall the income or separate property of that spouse be considered in the determination of eligibility of the GA applicant spouse. The SSI/SSP spouse shall not be required to apply for GA, but is required to sign the Statement of Facts and the Reimbursement Agreement. Verification of SSI/SSP status is required. Undocumented Non-citizen Spouse When a married couple includes an undocumented non-citizen, she/he is not eligible to receive GA and will be excluded in determining the Maximum Basic Need rate to be paid to the GA eligible spouse. Immigration status does not affect the spouse-for-spouse responsibility. All income and property of both spouses shall be included in the determination of eligibility. [Refer to Payment Principles, page 27-1 of the GA Handbook for an example of budgeting with an excluded spouse.] The undocumented non-citizen spouse must be added to CalWIN s Data Collection as an excluded person. All applicable windows including the Non Citizen Summary window must be completed to identify these cases. As an Example Process for CalWIN to Calculate the Shared Housing, page can be used on how to add as an excluded person.] Update # Revised: 04/15/16

28 page 6-28 General Assistance Handbook 6.16 Documentation Documentation in the CalWIN Maintain Case Comments window must reflect the applicant s situation. Discrepancies must be clarified. Do not assume what is occurring. Determine what is actually happening and then take appropriate action based on the situation. Regardless of what is occurring, documentation and verification must be in the case record so that the Supervisor, Co-Worker, Quality Control Examiner, State/Federal Auditors, IEVS Examiner, Appeals Examiner or anyone who reviews the case is able to accurately determine eligibility and grant level Case Comments The following information, NOT FOUND ELSEWHERE IN THE CASE, must be documented in the CalWIN Maintain Case Comments window: The content of the Intake interview, Any contacts, either written or by phone, indicating a change or a potential change in the case. Explain all the decisions made based on anticipated circumstances where an alternate action could have been taken. For example: Potential income may be anticipated depending upon the probability of receipt, i.e., day labor, anticipated UIB/DIB. Any justification for unusual or special actions taken by EW, Any information from Social Security including the SSN or any possible benefit information, The scheduling of appointments, Any additional or questionable information that would be helpful to an EW newly assigned the case. Reminder: THE APPLICANT MAY SEE THE CalWIN MAINTAIN CASE COMMENTS WINDOW AS PART OF THE CASE RECORD. THIS WINDOW IS USED ONLY TO STATE FACTUAL INFORMATION AND ACTIONS TAKEN OR PROPOSED. Revised: 04/15/16 Update #

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