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Mailing Address: P.O. Box 1515, Red Bluff, CA 96080
Red Bluff Office: (530) 527-1911 fax (530) 527-5410 310 South Main St.
Corning Office: (530) 824-9182 fax (530) 527-5410 275 Solano St. www.tcdss.org

Self-Attestation Form

Case Number (Enter unknown if you do not know)(*)

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First Name(*)

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Last Name(*)

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Phone Number

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Email Address

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Signature(*)

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Date(*)

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By signing and submitting this form, I am certifying that:

I have watched the CalWORKs Welfare-To-Work Orientation video

I have read the information located under Program Overview

I have read and understand my Rights and Responsibilities

I have viewed and/or received a copy of the CalWORKs Handbook

Please check the boxes to indicate that you have completed the requested actions.

TEH WTW 4 (4/2024)