Forms

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Form Type and Description
In-House
LA County
OC County
Attending Multiple Schools (GN6390): Form generated by the county GAIN Service Worker for students attending 2 or more colleges/universities at the same time.    X  
Continuing Student Intake: Internal form required every semester, along with County Approved Eligibility documentation (Verification of Benefits Form or Notice of Action) to maintain current contact information and keep students up to date with important changes or deadlines.
 X    
Employment Verification (Work-Study): Form generated by the county GAIN Service Worker to request verification of work-study participation.
     X
Intake (GN6006)- Service Provider Referral: Must be signed and include GN6013 & GN6014 Vocational Assessment.
  • Only needs to be completed once (unless told otherwise by your GAIN Case Worker)
  • Must be completed by a CalWORKs Counselor (may not be dropped off).
To fill out, you MUST:
  1. Be a Cerritos College student with a current student ID number.
  2. Be enrolled in at least 1 credit/non-credit course.
  3. Make a 1-hour CalWORKs counseling appointment.
   X  
Monthly Attendance Report (GN 6365): Form is generated by the GAIN Case Worker and must be completed and submitted every month. Due dates and deadlines are listed on the form or provided by the GAIN Case Worker.
 
These forms are NO LONGER required and do not need to be submitted to the county. 
 
  • Form has a 3-day turnaround period. Meaning that the form will be emailed to your GAIN Case Worker within 72 business hours.
  • Form must be completed and signed.
  • Please fill out the hours of class time you attended each day. Time spent in between classes does not count as class time.
  • Please DO NOT fill out the contact information. This is for the CalWORKs office use ONLY.
  • The student's signature must be at the bottom of the page.
  • If taking Online classes, make sure to separate Online class hours and attach the class schedule or course catalog class description with the hours required per week.
  • To request copies, please complete a Student Appeal (listed below).
  • These forms ARE REQUIRED to be submitted on a monthly basis on the 10th of every month. 
  • Please email the completed and signed form to CalWORKs to be processed and submitted to your caseworker.
   X  
New Student Intake: Internal form utilized to verify and obtain student information for a successful intake process. 
 X    
Notice of Action: Form generated by the GAIN Service Office, which notifies students of changes related to benefits.
   X  
Progress Report (GN 6070): Form generated and mailed to student by GAIN Service Worker.
 
These forms are NO LONGER required and do not need to be submitted to the county. 
 
  • These forms used to be required to be completed by a counselor and submitted to the county. HOWEVER, this has changed. 
  • Please disregard them when you receive them, UNLESS your county worker specifically needs them from you due to an audit. 
   X  
Student Appeal: Internal form used for deferments, work-study verification letters, or extension, and requesting copies or requesting to resubmit documents to county workers.
 X    
Verification of Welfare-To-Work Participation Hours (STI-20A): Form generated and mailed to student by GAIN Service Worker. Previously known as the Training Verification or Child Care Form.
  • Form must be completed at least once every semester. Due dates and deadlines are provided by the GAIN Case Worker.
  • Must be completed by a CalWORKs Counselor (may not be dropped off).
  • Requires a 30-minute CalWORKs counseling appointment.
   X X
Verification of Benefits: County form that verifies CalWORKs eligibility.
  • Los Angeles & Orange County form that verifies CalWORKs eligibility.
    • New Benefits Cal Platform
    • Cannot generate a Form? Is your case confidential?
  X X
Verification of Receipt of CalWORKs: Generated by the county case worker after being requested by students.
     X
Welfare-To-Work Attendance/Progress Report (41-06): Form generated and mailed to student by county service worker. 
  • These forms used to be required to be completed by a counselor and submitted to the county. HOWEVER, this has changed.
  • These forms are NO LONGER required and do not need to be submitted to the county.
  • Please disregard them when you receive them, UNLESS your county worker specifically needs them from you due to an audit. 
     X
Welfare-To-Work Referral For Education/Training: Form generated and mailed to student by county service worker. 
  • Only needs to be completed once (unless told otherwise by your GAIN Case Worker).
  • Must be completed by a CalWORKs Counselor (may not be dropped off).
To fill out, you MUST:
  1. Be a Cerritos College student with a current student ID number.
  2. Be enrolled in at least 1 credit/non-credit course.
  3. Make a 1-hour Intake CalWORKs counseling appointment.
  4. Make a 30-minute CalWORKs counseling appointment.
     X
Work-In Progress (WIP): Internal form used to check students' current course progress and must be completed every semester. Form is available for pick-up, via our website, and also available for download via Canvas.

Once the form has been completed by instructors, students must sign it and can drop it off in the CalWORKs office (no appointment needed), upload a copy via Canvas, or email it to CalWORKs.

If taking online classes:
  • Email instructors requesting the current course grade, and once a response is received, print and attach it to this form.
  • If the instructor has up-to-date grades on Canvas, print out the Canvas grade and attach it to this form.
  • For instructors with questions/concerns regarding this form, please refer them to EAP Program Facilitator, Blanca Gamez, at (562) 860-2451, Ext. 2377.
For students with courses where the grade is below a “C”, a CalWORKs Counseling appointment is required to discuss options and support services/interventions.
X