Application Calfresh Form – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

APPLICATION FOR CALFRESH BENEFITS

If you have a disability or need help with this application, let the County Welfare Department (County) know and someone will help you.

If you prefer to speak, read, or write in a language other than English, the County will get someone to help you at no cost to you.

How do I apply?

Use this application if you are applying for CalFresh benefits only. CalFresh is a food assistance program to help you with the cost of buying food for your household. If you wish to apply for programs other than CalFresh such

as, CalWORKs or Medi-Cal, please ask for an application to apply for other programs. You can also apply for CalFresh or other programs online by going to http://www.benefitscal.org/. You can see if you may be eligible by

going to http://www.cdss.ca.gov/foodstamps/PG849.htm.

•Fill out the whole application form, if you can. You must at least give the County your name, address, and signature (question 1 on page 1) to begin the application process.

•Give the application to the County in person, by mail, by fax, or online.

•The day the County receives your signed application starts the time to give you an answer on whether you can get benefits. If you are in an institution, this time starts from the day you leave.

What do I do next?

•Read about your rights and your responsibilities (Program Rules pages 1 through 5) before you sign the application.

•You must have an interview with the County to discuss your application. Most interviews are done by phone, but it can be done in person at the County office or other place arranged with the County. If you have a disability, other arrangements can be made.

•If you did not fill out all of the application, you can finish it during your interview.

•You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.

How long will it take?

It may take up to 30 days to process your application. You may be able to get benefits within 3 calendar days, if

you meet one of the Expedited Service criteria:

•Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand or in checking or savings accounts is $100 or less; or

•Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and cash on hand or in checking or savings accounts; or

•You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.

To help the County see if you can get benefits in three days, please answer questions 1, 6 through 8, 11, and 16, and give the County proof of your identify (if you have it) with the application.

The County will send you a letter to let you know if your household is approved or denied CalFresh benefits.

Agency Conference

Agency conference is a process that provides the household the right to request a meeting with an eligibility supervisor (this meeting may be attended by an eligibility worker and an authorized representative) to informally resolve any dispute as to whether the household meets Expedited Service criteria.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

The agency conference shall be scheduled within two working days of the request, unless the household requests that it be scheduled later or states that they do not wish to have an agency conference.

What do I need for my interview?

To avoid delays, bring proof of the following with you to your interview. Keep your interview even if you do not

have the proof. The County may be able to help if you need help getting proof. During the interview, the County will go over the information on the application and will ask you questions to see if you can get CalFresh benefits and the amount of benefits you can get.

Proof Needed to Get Benefits	Proof Needed to Get More CalFresh Benefits
• Identification (Driver’s License, State ID card, passport).	• Housing costs (rent receipts, mortgage bills,
• Where you live (a rental agreement, current bill with	property tax bill, insurance documents).
your address listed).	• Phone and utility costs.
• Social Security Numbers (see note below about certain	• Medical expenses for anyone in your household
noncitizens).	who is elderly (60 and older) or disabled.
• Money in the bank for all the people in your household	• Child and adult care costs due to someone
(recent bank statements).	working, looking for work, attending training
• Earned income of everyone in your household for the	or school, or participating in a required work
past 30 days (recent pay stubs, a work statement from	activity.
an employer). NOTE: If self-employed, income and	• Child support paid by a person in your
expense or tax records.	household.

•Unearned income (Unemployment benefits, SSI, Social Security, Veteran’s benefits, child support, worker’s compensation, school grants or loans, rental income, etc.).

•Lawful immigration status ONLY for noncitizens applying for benefits (an Alien Registration Card, visa).

NOTE: Certain noncitizens applying for immigration

status based on domestic violence, crime prosecution or trafficking may not need this proof. They also may not need a Social Security Number.

How do I get/use my CalFresh benefits?

•The County will mail or give you a plastic Electronic Benefit Transfer (EBT) card. Benefits will be put on

the card when your application is approved. Sign your card when you get it. You will set up a Personal

Identification Number (PIN) to use your card.

•If your EBT card is lost, stolen, or destroyed, or you think someone may know your PIN number that you don’t want to use your benefits call (877) 328-9677 or call the County right away. Make sure all responsible adults

and your authorized representative also know how to report one of these problems right away. If you do not report that another person you do not want to spend your benefits has your PIN and you do not get your PIN changed, any benefits used will not be replaced.

•You can use your CalFresh benefits to buy almost all foods, as well as seeds and plants to grow your own food. You cannot buy alcohol, tobacco, pet food, some types of cooked food, or anything that is not food (like toothpaste, soap, or paper towels).

•CalFresh benefits are accepted at most grocery stores and other places that sell food. For a list of locations near you that accept EBT please go to: https://www.ebt.ca.gov or https://www.snapfresh.org.

•CalFresh benefits are only for you and your household members. Keep your benefits safe. Do not give out your PIN number. Do not keep your PIN number with your EBT card.

What if I am homeless?

Please let the County know right away if you are homeless so they can help you figure out an address to use to accept

your application and get notices from the County regarding your case. For CalFresh, homeless means you are:

A.Staying in a supervised shelter, halfway house, or similar place.

B.Staying at the home of another person or family for no more than 90 days straight.

C.Sleeping in a place not designed for, or normally used as, a place to sleep (e.g., a hallway, a bus station, a lobby, or similar places).

Informational Page - Please take and keep for your records.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

RIGHTS AND RESPONSIBILITIES

You have a responsibility to:

•Give the County all information needed to determine your eligibility.

•Give the County proof of the information you have when it is needed.

•Report changes as required. The County will give you information about what, when, and how to report. If you don’t meet your household’s reporting requirements your case will be closed or your CalFresh benefits may be lowered or stopped.

•Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your case.

•Fully cooperate with County, State, or federal personnel if your case is selected for review or investigation to ensure that your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will result in loss of your benefits.

•Pay back any CalFresh benefits that you were not eligible to get.

You have the right to:

•Turn in an application for CalFresh giving only your name, address, and signature.

•Have an interpreter provided by the State at no cost if you need one.

•Have information given to the County kept confidential, unless directly related to the administration of County programs.

•Withdraw your application at any time prior to the County determining eligibility.

•Ask for help to fill out your application for CalFresh and get an explanation of the rules.

•Ask for help to get proof that is needed.

•Be treated with courtesy, consideration, and respect, and not be discriminated against.

•Get CalFresh benefits within 3 days if you qualify for Expedited Service.

•Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility determined within 30 days.

•Get at least 10 days to give the County proof that is needed to make a determination of eligibility.

•Get written notice at least 10 days before the County lowers or stops your CalFresh benefits.

•Discuss your case with the County and to review your case when you ask to do so.

•Ask for a State hearing within 90 days if you do not agree with the County about your CalFresh case. If you ask for a hearing before an action on your CalFresh case takes place, your CalFresh benefits will stay the same until the hearing or the end of your certification period, whichever is earlier. You can ask the County to let your benefits change until after the hearing to avoid having to pay back any over paid benefits. If the Administrative Law Judge rules in your favor, the County will give back to you any benefits that were cut.

•Ask about your hearing rights or for a legal aid referral at the toll-free phone number – 1-800-952-5253 or for

hearing or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal aid or welfare rights office.

•Bring a friend or someone with you to the hearing if you do not want to go alone.

•Get assistance from the County to register to vote.

•Report changes that you are not required to report, if it may increase your CalFresh benefits.

•Give proof of your household’s expenses that may help you get more CalFresh benefits. Not giving proof to the County is the same as saying that you do not have that expense and you will not be able to get more

CalFresh benefits.

•Let the County know if you would like someone else to use your CalFresh benefits for your household or help with your CalFresh case (Authorized Representative).

Please take and keep for your records

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PROGRAM RULES PAGE 1 OF 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Program Rules and Penalties

You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get CalFresh benefits that you are not eligible to receive, or to help someone else get benefits that they are not eligible to receive. You must pay back any benefits you get that you were not eligible to receive.

	Program Violations	Penalties
	For CalFresh: I understand I may have	I may:
	committed an intentional program violation if	• Lose CalFresh benefits for 12 months for the first
	I do any of the following:	offense and be required to repay all CalFresh
	• Hide information or make false statements	benefits overpaid to me
	• Use Electronic Benefit Transfer (EBT) cards that	• Lose CalFresh benefits for 24 months for the
	belong to someone else or let someone else use	second offense and be required to repay all
	my card	CalFresh benefits overpaid to me
	• Use CalFresh benefits to buy alcohol or tobacco	• Lose CalFresh benefits permanently for the third
	• Trade, buy, sell, steal or give away CalFresh	offense and be required to repay all CalFresh
		benefits overpaid to me
	benefits or EBT cards, or attempt to trade, buy,
		• Be fined up to $250,000.00, imprisoned up to 20
	sell, steal or give away CalFresh benefits or EBT
	cards	years or both
	• Try to get dual benefits, for example, apply in two
	or more different counties or states at the same
	time
	• Submit false documents for children or adult
	household members who are not eligible or who
	do not exist
	• Violate conditions of my probation or parole
	• Flee after a felony conviction
	• Purchase (buy) a product with CalFresh benefits
	that has a return deposit, intentionally (on
	purpose) throw away the contents and return the
	container for the deposit amount or attempt to
	return the container for the deposit amount
	• Buy a product with CalFresh benefits and
	intentionally resell it for cash or anything other
	than eligible food
	• Trade CalFresh benefits or attempt to trade	• Lose CalFresh benefits for 24 months for the first
	CalFresh benefits for: cash, firearms, non-	offense
	eligible goods or controlled substances such as	• Lose CalFresh benefits permanently for the
	drugs	second offense
	• Give false information about who I am and where I	• Lose CalFresh benefits for 10 years for each
	live so I can get extra CalFresh benefits	offense
	• Have been convicted of trading, selling or	• Lose CalFresh benefits permanently
	attempting to trade CalFresh benefits worth
	more than $500, or trading or attempting to
	trade CalFresh benefits for firearms, ammunition
	or explosives

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Important Information for Noncitizens

•You can apply for and get CalFresh benefits for people who are eligible, even if your family includes others who are not eligible. For example, immigrant parents may apply for CalFresh benefits for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible.

•Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and confidential.

•The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S.

Citizenship and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except cases of fraud.

Opting Out

You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s) who are not applying for CalFresh benefits. The County will need to know their income and resource information to correctly determine your household’s benefits. The County will not contact USCIS about the people who don’t apply for CalFresh benefits.

Privacy Act and Disclosure: You are giving personal information in the application. The County uses the

information to see if you are eligible for benefits. If you do not give the requested information, the County may

deny your application. You have the right to review, change, or correct any information that you gave to the

County. The County will not show your information or give it to others unless you give them permission or federal and state law allows them to do so. 273.2(b)(4) Privacy Act statement. As a County agency, we must notify all households applying and being recertified for CalFresh benefits of the following:

(i) The collection of this information, including the social security number (SSN) of each household member, is authorized under the Food Stamp Act of 1977, as amended, 7 U.S.C. 2011-2036. The information will be

used to determine whether your household is eligible or continues to be eligible to participate in the CalFresh Program. We will verify this information through computer matching programs, including the Income and

Earnings Verification System (IEVS). This information will also be used to monitor compliance with program

regulations and for program management.

(ii)This information may be disclosed to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.

(iii)If a CalFresh claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.

(iv)Providing the requested information including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of CalFresh benefits to each individual failing to provide an

SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.

The County may verify immigration status of household members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your eligibility and level of benefits.

The County will check your answers using information in state and federal electronic databases from the Internal Revenue Service (IRS), Social Security Administration, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, the County may ask you to send proof.