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The California Rs 3 form serves as a crucial document within the state’s welfare system, particularly for individuals seeking cash assistance through programs such as Refugee Cash Assistance (RCA) and CalWORKs. This mandatory referral form facilitates the connection between applicants and service providers, ensuring that individuals comply with eligibility requirements. It requires specific information, including the case name, aid code, and registrant details, such as social security and alien numbers. Additionally, the form outlines the necessity for clients to report to designated service providers to maintain their eligibility for benefits. It includes sections for scheduling appointments and provides space for comments, allowing for clear communication between the client, service provider, and county welfare department. Upon completion of the training program or employment placement, the service provider must notify the county welfare department, highlighting the importance of this form in tracking participant progress. Ultimately, the Rs 3 form is essential for both administrative compliance and the support of individuals navigating the welfare system.

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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

 

 

 

 

TELEPHONE NO.: (

)

---

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

DATE

 

 

 

 

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 ______________________

 

(see attached RS 3A)

DATE

18. COMMENTS

19.SERVICE PROVIDER AUTHORIZED SIGNATURE

RS 3 (10/03)

DATE

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.

➤ PDF File

Form Specifications

Fact Name Description
Purpose The California RS 3 form is used for mandatory referrals of clients to service providers under the RCA and CalWORKs programs.
Governing Laws This form is governed by California Welfare and Institutions Code Sections 11200-11204, which outline the requirements for cash assistance eligibility.
Distribution Upon completion, the original copy goes to the client, the first copy is for the service provider, and the second copy is returned to the County Welfare Department.
Client Responsibilities Clients must report to the service provider and return the dated original form to their worker to maintain eligibility for cash assistance.
Completion Requirements Service providers must complete the form after the client has participated in training or been placed in employment, returning the necessary copies to the county.

California Rs 3: Usage Guidelines

Filling out the California RS 3 form is a straightforward process. Follow these steps carefully to ensure that all required information is provided accurately. Once completed, the form will need to be submitted to the appropriate county welfare department.

  1. Case Name: Enter the refugee’s name in the format of last name, first name, and middle initial.
  2. AU Size: Indicate the number of persons in the Assistance Unit.
  3. Aid Code/Case Number: Provide the two-digit aid identification code for the relevant public assistance program, along with the refugee’s case number as assigned by your County Welfare Department (CWD).
  4. Registrant’s Name: Enter the name of the person in the AU who is being referred on a mandatory basis.
  5. Social Security Number: Fill in the registrant’s social security number.
  6. Alien Number: Input the registrant’s alien number.
  7. Date of Entry or Asylum: Enter the date from the registrant’s I-94 form or I-551 form.
  8. Intracounty or Intercounty Transfer: Specify the county or district from which the registrant is transferring.
  9. Primary Language: Indicate the primary language designated on SAWS 1.
  10. Date of Referral: Enter the date the registrant is referred to the Service Provider.
  11. Reporting Requirement: Check the appropriate box and enter the date the registrant must return the validated original RS 3 form to the Worker.
  12. Appointment Details: If applicable, check the box for the appointment and enter the date and time.
  13. Service Provider Address: Fill in the full address and telephone number of the Service Provider.
  14. Comments: Use this section for any additional notes or information.
  15. Worker’s Name and Number: Enter the assigned worker's name and their identification number.
  16. Authorized Signature: This must be signed by the person certifying that the registrant has reported to the Service Provider.
  17. Service Provider Embossing Stamp: Affix the official certification stamp here.
  18. Reason for Notification: Check the appropriate box to indicate why the notification is being made.
  19. Comments: Provide any additional notes as necessary.
  20. Service Provider Authorized Signature: This should be signed and dated by the authorized person completing the form.

Your Questions, Answered

What is the California RS 3 form?

The California RS 3 form is a mandatory referral and notification form used by the California Department of Social Services. It is primarily for individuals receiving cash assistance through programs like RCA (Refugee Cash Assistance) and CalWORKs. This form ensures that clients report to designated service providers as part of their eligibility requirements for cash assistance. It helps facilitate the necessary connections between clients and service providers, which can include training and employment opportunities.

Who needs to fill out the RS 3 form?

The RS 3 form must be completed for individuals who are part of an Assistance Unit (AU) and are required to register with a service provider. This includes refugees and certain eligible individuals seeking cash assistance. The form must be filled out by a county welfare worker and includes essential details such as the client's name, social security number, and appointment information with the service provider.

What happens after the RS 3 form is submitted?

Once the RS 3 form is submitted, the client must report to the designated service provider by the specified date. The service provider will then verify the client's attendance and participation. After completing the required activities, the service provider will return copies of the form to the county welfare department, indicating whether the client has fulfilled their obligations. This process is crucial for maintaining eligibility for cash assistance.

What should I do if I miss my appointment with the service provider?

If you miss your appointment, it is important to contact the service provider as soon as possible. They may be able to reschedule your appointment. Missing the appointment could affect your eligibility for cash assistance, so taking prompt action is essential. You may also want to inform your county welfare worker about the situation to discuss any potential impacts on your case.

Can I get help filling out the RS 3 form?

Yes, assistance is available for filling out the RS 3 form. You can reach out to your county welfare department for guidance. They can provide support and answer any questions you may have about the form and the process. Additionally, service providers may also offer help to ensure that you complete the form correctly and understand your responsibilities.

Common mistakes

  1. Incorrect Personal Information: One common mistake is entering the wrong details for the registrant. This includes the name, social security number, or alien number. Double-checking these details can help avoid complications later.

  2. Missing Signatures: Not signing the form can lead to delays. Both the worker's signature and the service provider's signature are essential. Make sure these are included before submission.

  3. Omitting Required Dates: Failing to fill in important dates, such as the referral date or appointment date, can cause confusion. Ensure all necessary dates are clearly stated to keep the process moving smoothly.

  4. Not Following Instructions: Each section of the form has specific instructions. Ignoring these can result in incomplete information. Take the time to read and follow the guidelines carefully to ensure accuracy.

Documents used along the form

The California Rs 3 form is an essential document used in the state's welfare system, specifically for mandatory referrals to service providers. Alongside this form, there are several other important documents that often come into play. Here’s a brief overview of four commonly used forms and documents that work in conjunction with the Rs 3.

  • RS 3A Form: This form is used to provide additional information regarding the client's participation in training programs or employment. It helps keep the county welfare department informed about the client's progress and compliance with program requirements.
  • SAWS 1 Form: The SAWS 1 form is utilized to determine a client's eligibility for various assistance programs. It collects essential information about the client’s household, income, and other factors that affect their eligibility for cash assistance and services.
  • CalWORKs Application: This application is specifically for the California Work Opportunity and Responsibility to Kids (CalWORKs) program. It outlines the necessary information needed for families to receive cash aid and support services, helping them transition to self-sufficiency.
  • Verification Documents: Clients may need to provide various verification documents, such as pay stubs, identification, or proof of residency. These documents help verify the information provided in the Rs 3 and other forms, ensuring that clients meet eligibility requirements.

Understanding these documents can streamline the process of applying for assistance and ensure compliance with program requirements. Having everything in order makes a significant difference in receiving timely support.

Similar forms

The California RS 3 form is similar to several other documents used in social services and public assistance programs. Below are six documents that share characteristics with the RS 3 form:

  • California RS 1 Form: This form is used for reporting changes in a recipient's circumstances. Like the RS 3, it requires personal information and serves as a notification tool for the county welfare department.
  • California RS 2 Form: This document is a verification of employment for individuals receiving assistance. Similar to the RS 3, it confirms participation in required programs and is submitted to the county welfare department.
  • California CalWORKs Referral Form: This form facilitates referrals to service providers for CalWORKs participants. It shares the mandatory reporting aspect of the RS 3, ensuring compliance with program requirements.
  • Welfare-to-Work Program Participation Form: This form documents participation in employment activities. It is similar to the RS 3 in that it tracks compliance and is used to communicate with the county welfare department.
  • California Medi-Cal Referral Form: This document is used to refer individuals for Medi-Cal services. Like the RS 3, it requires personal details and serves as a notification to the relevant service provider.
  • Service Provider Notification Form: This form notifies the county welfare department when a client has engaged with a service provider. It parallels the RS 3 in its purpose to ensure communication between the client, service provider, and county.

Dos and Don'ts

Filling out the California RS 3 form can seem daunting, but with the right approach, it becomes much easier. Here are some important dos and don'ts to keep in mind:

  • Do read the instructions carefully before starting.
  • Do ensure all names and numbers are entered accurately.
  • Do double-check the appointment date and time before submission.
  • Do keep a copy of the completed form for your records.
  • Don't leave any required fields blank; incomplete forms can delay processing.
  • Don't forget to sign the form where indicated.
  • Don't hesitate to ask for help if you are unsure about any section.

By following these guidelines, you can help ensure that your form is filled out correctly and submitted on time. Good luck!

Misconceptions

Understanding the California Rs 3 form can be challenging due to various misconceptions. Here are six common misunderstandings clarified:

  • Misconception 1: The Rs 3 form is optional for recipients.

    • This is incorrect. The Rs 3 form is mandatory for individuals receiving cash assistance. They must report to the service provider as part of their eligibility requirements.

  • Misconception 2: Only new applicants need to complete the Rs 3 form.

    • In reality, existing recipients who are referred for services must also complete this form. It is part of ongoing compliance with program requirements.

  • Misconception 3: The form can be submitted at any time.

    • This is not true. There are specific deadlines for submitting the Rs 3 form. Recipients must return it to their worker by the designated date to maintain their assistance.

  • Misconception 4: The Rs 3 form is only for refugees.

    • While the form is specifically designed for refugees and asylees, it can also apply to other individuals receiving cash assistance under certain programs.

  • Misconception 5: Once the form is submitted, no further action is needed.

    • This is misleading. After submitting the Rs 3 form, recipients must still participate in training and employment activities as required. Failure to do so can lead to loss of benefits.

  • Misconception 6: The service provider will handle everything after the form is submitted.

    • This is a misconception. Recipients are responsible for ensuring they comply with all requirements outlined in the Rs 3 form, including attending appointments and reporting back to their worker.

Key takeaways

Here are the key takeaways regarding the California RS 3 form:

  • Purpose: The RS 3 form is used for mandatory referrals to service providers for individuals receiving cash assistance in California.
  • Distribution: The form has multiple copies: the original goes to the client, the first copy to the service provider, and the second copy returns to the County Welfare Department.
  • Completion: Accurate information must be provided, including the case name, aid code, and registrant's details.
  • Appointment Requirement: Clients must report to the service provider before becoming eligible for cash assistance.
  • Language Specification: The primary language of the registrant should be indicated on the form.
  • Return Deadline: The original RS 3 form must be returned to the worker by a specified date.
  • Service Provider Details: Include the full address and telephone number of the service provider to ensure proper communication.
  • Certification: The worker must certify that the applicant has been informed of their rights and responsibilities regarding the RCA/ECA programs.
  • Notification Reasons: The service provider must indicate why notification to the county welfare department is necessary, such as completion of training or employment placement.
  • Authorized Signatures: Both the worker and service provider must provide their signatures to validate the form.

Ensure all sections are filled out completely and accurately to avoid delays in processing. Adherence to deadlines is crucial for maintaining eligibility for assistance.