The California RS 3 form is a notification tool used by the Department of Social Services to refer individuals for mandatory services under the Refugee Cash Assistance (RCA) and CalWORKs programs. This form ensures that clients understand their responsibilities and eligibility requirements for receiving cash assistance. To get started on your application process, please fill out the form by clicking the button below.
The California RS 3 form serves as a crucial document in the process of providing support to individuals and families in need of assistance. This form is specifically designed for clients participating in programs such as the Refugee Cash Assistance (RCA) and CalWORKs, ensuring that they meet all eligibility requirements for cash assistance. It requires essential information, including the registrant's name, social security number, and details about their service provider appointment. The form also includes sections for case identification, reporting obligations, and comments, which help streamline communication between clients, service providers, and county welfare departments. Timely submission of the RS 3 form is vital, as it outlines the responsibilities of the registrant to report to the designated service provider, participate in training and employment activities, and comply with all program requirements. Failure to adhere to these stipulations may result in the loss of benefits, making it imperative for clients to understand and complete the form accurately. The RS 3 form not only facilitates the necessary referrals but also plays a significant role in tracking client progress and ensuring that support services are effectively delivered.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
■ RCA MANDATORY REFERRAL
■ CALWORKS MANDATORY REFERRAL
SERVICE PROVIDER
REFERRAL / NOTIFICATION FORM
DISTRIBUTION:
Original Copy:
Client
1st Copy
:
Service Provider
2nd Copy
Return to County Welfare Department When Notification is Required
3rd Copy
County Welfare Department
ADDRESS OF COUNTY WELFARE DEPARTMENT
TELEPHONE NO.: (
)
----
COUNTY USE ONLY
1.
CASE NAME
2. AU SIZE
11. YOU ARE REQUIRED TO REPORT TO THE SERVICE PROVIDER
3.
AID CODE/CASE NUMBER
BEFORE YOU CAN BE ELIGIBLE FOR CASH ASSISTANCE.
A. ■ PLEASE TAKE THIS FORM TO THE FOLLOWING SERVICE
4.
REGISTRANT’S NAME
PROVIDER AND RETURN TO YOUR WORKER WITH DATED
ORIGINAL ON OR BEFORE _______________ .
5.
SOCIAL SECURITY NUMBER
B. ■ YOUR APPOINTMENT AT THE SERVICE PROVIDER IS
6.
ALIEN NUMBER
A -
SCHEDULED FOR:
7.
DATE OF ENTRY AS A REFUGEE, OR DATE GRANTED ASYLUM, OR DATE OF CERTIFICATION AS A
DATE:_________________
TIME:_________________
TRAFFICKING VICTIM
8. INTRACOUNTY OR INTERCOUNTY TRANSFER
FROM:
COUNTY/DISTRICT
12.
SERVICE PROVIDER ADDRESS
PREVIOUS SERVICE PROVIDER:
9. SPECIFY PRIMARY LANGUAGE DESIGNATED ON SAWS 1
10.
DATE OF REFERRAL
---
13.
COMMENTS
14. I certify that I have informed the applicant/recipient of his or her rights and responsibilities in regard to the RCA/ECA programs. I have explained t h a t h e / s h e m u s t c o m p l y w i t h a l l e l i g i b i l i t y r e q u i r e m e n t s , s u c h a s r e p o r t i n g t o , a n d r e g i s t e r i n g w i t h t h e S e r v i c e P r o v i d e r , and participating and cooperating in training and employment activities, and that, if these requirements are not met, he/she may lose their grant.
WORKER’S SIGNATURE
WORKER’S NUMBER
DATE
SERVICE PROVIDER USE ONLY
15. Individual reported to Service Provider as required.
16. SERVICE PROVIDER EMBOSSING STAMP
AUTHORIZED SIGNATURE
When the above named registrant has completed participation in the training program or been placed in employment, please complete the 1st and 2nd copies and return the 2nd copy to the county welfare department addressed above.
17. Reason for notification to the county welfare department:
■ Client has completed participation in training.
■ Other (Explain in COMMENTS section)
■
(see attached RS 3A)
Client has been placed in employment on ______________________
18. COMMENTS
19.SERVICE PROVIDER AUTHORIZED SIGNATURE
RS 3 (10/03)
SERVICE PROVIDER REFERRAL FORM
Instructions
County Use Only
1.Case Name --- Enter the refugee’s name: last name, first name, and middle initial.
2.AU Size --- Enter number of persons in the Assistance Unit
3.Aid Code/Case Number --- Enter the two-digit aid identification code for the appropriate public assistance program/Enter the refugee’s case number as assigned by your CWD.
4.Registrant’s Name --- Enter the name of person in the AU who is being referred on a mandatory basis, and required to register with the Service Provider.
5.Social Security Number --- Enter the registrant’s social security number.
6.Alien Number --- Enter the registrant’s alien number.
7.Date of Entry to U.S. or Date Granted Asylum --- Enter the date shown on the registrant’s I-94 form or I-551 form or other appropriate documentation.
8.Intracounty or Intercounty Transfer --- Enter the county (or district, if Los Angeles), and the Service Provider name and address that the registrant is transferring from.
9.Specify primary language designated on SAWS 1.
10.Date of Referral --- Enter the date on which the registrant is referred to the Service Provider.
11a. Check this box and enter the date that the registrant is to return the validated original RS 3 form to the Worker.
11b. If you make an appointment for the registrant to report to the Service Provider, check this box and enter the date and time of the appointment.
12.Service Provider Address --- Enter the address and telephone number of the Service Provider the registrant is being referred to. Enter the Service Provider’s full address including, number, street, city and zip code.
13.Comments --- Self-explanatory.
14.Worker Name and Worker Number --- Enter the name of worker assigned to the case, and the number that your county uses to identify the worker.
Service Provider Use Only
15.Authorized Signature --- This is to be signed by the person authorized to certify that the registrant has reported to the Service Provider for registration.
16.Service Provider Embossing Stamp --- Enter the official certification stamp.
17.Check the appropriate box to indicate why notification is being made.
18.Comments --- Self-explanatory.
19.Service Provider Authorized Signature --- This is to be signed and dated by the person authorized to complete this form.
Filling out the California Rs 3 form is an important step in ensuring that individuals receive the necessary support and services. After completing the form, it will need to be submitted to the appropriate county welfare department, where it will be processed. Follow these steps carefully to ensure accuracy and compliance.
What is the California RS 3 form?
The California RS 3 form is a mandatory referral notification form used within the California Department of Social Services. It is primarily designed for individuals receiving cash assistance through programs like RCA (Refugee Cash Assistance) and CalWORKs. This form ensures that clients are referred to service providers for necessary training and employment activities.
Who needs to fill out the RS 3 form?
The RS 3 form must be filled out for individuals in the Assistance Unit (AU) who are required to register with a service provider. This typically includes refugees and other eligible individuals receiving cash assistance. The caseworker is responsible for completing the form and providing it to the client.
What information is required on the RS 3 form?
Essential information includes the case name, AU size, aid code or case number, registrant’s name, social security number, alien number, date of entry to the U.S., and the service provider's address. Additional details such as the primary language and appointment date may also be necessary.
How should the RS 3 form be submitted?
The original RS 3 form must be submitted to the designated service provider. The client should return the dated original to their caseworker by the specified deadline. Copies of the form are distributed to the client and the service provider for their records.
What happens if a client does not report to the service provider?
If a client fails to report to the service provider as required, they may risk losing their cash assistance grant. Compliance with all eligibility requirements is crucial for continued support.
What is the role of the service provider regarding the RS 3 form?
The service provider is responsible for certifying that the client has reported for registration. They must complete the form upon the client's participation in training or placement in employment and return the necessary copies to the county welfare department.
What should clients do if they have questions about the RS 3 form?
Clients should reach out to their assigned caseworker for clarification or assistance regarding the RS 3 form. The caseworker can provide guidance on completing the form and understanding the referral process.
Is there a deadline for submitting the RS 3 form?
Yes, the RS 3 form must be returned to the caseworker by a specified date, which is indicated on the form. It is important for clients to adhere to this timeline to maintain their eligibility for cash assistance.
What should be done if there are errors on the RS 3 form?
If errors are identified on the RS 3 form, clients or caseworkers should correct them promptly. It is essential to ensure that all information is accurate to avoid complications in the referral process.
Where can clients find more information about the RS 3 form?
Clients can find additional information about the RS 3 form by visiting the California Department of Social Services website or by contacting their local county welfare department for specific guidance and resources.
Filling out the California RS 3 form can be a straightforward task, but many individuals encounter common pitfalls that can lead to complications. One frequent mistake is failing to provide the correct case name. This section requires the full name of the refugee, including the last name, first name, and middle initial. Omitting any part of this information can result in delays or miscommunication with the county welfare department.
Another common error is related to the aid code or case number. Applicants often either enter an incorrect code or leave this section blank. Each public assistance program has a specific two-digit aid identification code. Ensuring that this code is accurate is crucial for processing the application efficiently. Missing or incorrect information in this area can lead to significant delays in eligibility determination.
In addition to these issues, many people neglect to include the social security number of the registrant. This information is vital for verifying the identity of the individual being referred. Without it, the county welfare department may struggle to locate the correct records, which can further complicate the assistance process. It is essential to double-check that this number is both accurate and complete.
Another mistake often made involves the service provider address. Applicants sometimes provide incomplete or incorrect addresses, which can hinder the referral process. The form requires the full address, including street number, city, and zip code. Ensuring this information is precise will help in avoiding any unnecessary delays in receiving assistance.
Lastly, individuals frequently overlook the importance of the comments section. This area allows for additional notes or explanations that may be pertinent to the case. Failing to utilize this section can lead to misunderstandings or a lack of clarity regarding the registrant's situation. Providing thorough and clear comments can facilitate smoother communication between the service provider and the county welfare department.
The California Rs 3 form is an important document used in the state's welfare system. It is often accompanied by several other forms and documents that help streamline the process for clients. Below is a list of other forms that are frequently used alongside the Rs 3 form, along with a brief description of each.
Each of these documents plays a vital role in the welfare process, ensuring that clients receive the support they need while complying with program requirements. Proper completion and submission of these forms can help facilitate a smoother experience for all involved.
The California RS 3 form serves as a crucial document for individuals receiving assistance through various social services. Similar forms exist to facilitate communication between clients and service providers. Below are four documents that share similarities with the RS 3 form:
Filling out the California RS 3 form can be a straightforward process if you keep a few important things in mind. Here’s a list of what you should and shouldn’t do to ensure your form is completed correctly.
By following these guidelines, you can navigate the process of filling out the California RS 3 form with confidence and ease. Remember, attention to detail is key to ensuring your application is processed smoothly.
Understanding the California Rs 3 form is essential for those navigating the state's welfare system. However, several misconceptions often cloud its purpose and use. Here are eight common misunderstandings:
Addressing these misconceptions can help individuals navigate the welfare system more effectively and ensure they meet all necessary requirements for assistance.
When filling out and using the California RS 3 form, it is essential to understand its purpose and requirements. Here are some key takeaways:
Understanding these aspects will help ensure that the RS 3 form is filled out correctly and used effectively within the public assistance framework in California.