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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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.

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

Use of Social Security Numbers (SSN)

Everyone applying for CalFresh benefits needs to provide a SSN, if they have one, or proof that they have applied for a SSN (such as a letter from the Social Security Office). The County may deny CalFresh benefits for you or

any member of your household who does not give us a SSN. Some people do not have to give SSN’s to get help such as, victims of domestic abuse, crime prosecution witnesses, and trafficking victims.

Overissuance

This means you got more CalFresh benefits than you should have. You will have to pay it back even if the County made an error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of benefits owed, through the courts, other collection agencies, or federal government

collection action.

Reporting

Every household that gets CalFresh benefits must report certain changes. Your County will tell you what changes

to report, how to report them, and when to report them. Failure to report the changes may result in your CalFresh

benefits being lowered or stopped. You can also report if things happen that may increase your benefits, such

as getting less income.

State Hearing

You have the right to a State hearing if you do not agree with any action taken regarding your application or your

ongoing benefits. You can request a State hearing within 90 days of the County’s action and you must tell why

you want a hearing. The approval or denial notice you receive from the County will have information on how to request a State hearing. If you ask for a hearing before the action happens, you may be able to keep your

CalFresh benefits the same until a decision is made.

Nondiscrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices and employees, and institutions

participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille,

large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available

in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD 3027) found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or contact your

County’s Civil Rights Coordinator, or write a letter addressed to USDA and provide in the letter all of the information

requested in the form or write to California Department of Social Services (CDSS) address below. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail:	U.S. Department of Agriculture	CDSS
	Office of the Assistant Secretary for Civil Rights	Civil Rights Bureau
	1400 Independence Avenue, S.W.	P.O.BOX 944243, M.S. 8-16-70
	Washington D.C. 20250-9410	Sacramento, CA 94244-2430
(2) fax:	(202) 690-7442; or	1-866-741-6241 (Toll Free)
(3) email:	program.intake@usda.gov

This institution is an equal opportunity provider.

Please take and keep for your records

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

Case File Reviews

Your case may be selected for additional review to ensure that your eligibility was correctly figured. You must

cooperate fully with the County, State, or federal personnel in any investigation or review, including a quality control review. Failure to cooperate in these reviews could result in loss of your benefits.

Work Rules for CalFresh

The County may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.

You may not be eligible for CalFresh if you have recently quit a job without a good reason.

EBT Usage

Any benefit taken from your account before you, another household member, or your authorized representative report the EBT card or PIN has been lost or stolen will not be replaced.

Any use of your EBT card by you, a household member, your authorized representative, or anyone you voluntarily give your EBT card and PIN to will be considered approved by you and any benefits taken from your account

will not be replaced.

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.

Please take and keep for your records

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

NOTES

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

Please use black or blue ink because it is easy to read and copies best. Please print your answers.

If you need more space to answer a question(s), use page 10 “Additional Writing Space” section and attach additional sheets of paper if needed to provide the information. Please be sure to identify which question you are writing about in the extra space or on the additional sheets of paper.

1. APPLICANT’S INFORMATION

NAME (FIRST, MIDDLE, LAST)	OTHER NAMES (MAIDEN, NICKNAMES, ETC.)		SOCIAL SECURITY NUMBER (IF YOUR HAVE ONE
			AND ARE APPLYING FOR BENEFITS)
HOME ADDRESS OR DIRECTIONS TO YOUR HOME		CITY		STATE	ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)		CITY		STATE	ZIP CODE

CONTACT AUTHORIZATION

Please give the county the best contact information to reach you. This will help in processing your application. By providing your contact information below, you are authorizing the county to contact you by phone, email or text, or to leave a phone message regarding your application.

		HOME PHONE			CELL PHONE	CHECK BOX FOR TEXT
						n
		WORK/ALTERNATIVE/MESSAGE PHONE			EMAIL ADDRESS
	Are you homeless?		Yes	No If yes, 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 about your case.
	What language do you prefer to read (if not English)?_______________________________________
	What language do you prefer to speak (if not English)?______________________________________
	The County will provide an interpreter at no cost to you. If you are deaf or hard of hearing please check here
	Do you or anyone in your household have a disability (optional question)?					(PLEASE CHECK ONE)
						Yes	No
Do you or anyone in your household need an accommodation due to a disability (optional question)?						Yes	No

	Are you interested in applying for Medi-Cal? If you answer yes the County will use your answers to	Yes	No
	find out if you can get Medi-Cal.
	Is your household’s monthly gross income less than $150 and cash on hand, or in checking and	Yes	No
	savings accounts is $100 or less?
	Is your household’s combined monthly gross income and cash on hand or in checking and savings accounts	Yes	No
	less than the combined cost of rent/mortgage and utilities?
	Is your household a migrant/seasonal farm worker household with liquid resources not exceeding $100	Yes	No
	and either your income stopped or you will not get more than $25 in the next 10 days?

I understand that by signing this application under penalty of perjury (making false statements), that:

•I read, or had read to me, the information in this application and my answers to the questions in this application.

•My answers to the questions are true and complete to the best of my knowledge.

•Any answers I may give for my application process will be true and complete to the best of my knowledge.

•I read or had read to me and I understand and agree to the Rights and Responsibilities (Program Rules Page 1) for the CalFresh Program.

•I read, or had read to me, the CalFresh Program Rules and Penalties (Program Rules Page 2).

•I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for

CalFresh is fraud. Fraud can cause a criminal case to be filed against me and/or I may be barred for a period of time (or life) from getting CalFresh benefits.

•I understand that Social Security Numbers or immigration status for household members applying for benefits may be shared with the appropriate government agencies as required by federal law.

*If you have an Authorized Representative please complete question 2 on the next page.

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

2.HOUSEHOLD’S AUTHORIZED REPRESENTATIVE

You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for you at the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may get by mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be replaced. If you

are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.

3.RACE/ETHNICITY

Race and ethnicity information is optional. It is requested to assure that benefits are given without regard to race, color, or national origin. Your answers will not affect your eligibility or benefit amount. Check all that apply to you. The law says the County must record your

ethnic group and race.

Check this box if you do not want to give the County information about your race and ethnicity. If you do not, the County will enter this information for civil rights statistics only.

RACE/ETHNIC ORIGIN

Other Asian (specify) _________________________________________________________________

Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following):

4. INTERVIEW PREFERENCE

You or another adult member in your household will need to have an interview with the County to discuss your application and to receive

CalFresh benefits. Interviews for CalFresh are usually done by phone, unless you can be interviewed when giving your application to the County in person or would prefer an in-person interview. In-person interviews will only happen during the County’s normal office hours.

5. OTHER PROGRAMS

Have you or anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Medicaid, Supplemental

Nutrition Assistance Program [CalFresh], General Assistance (GA)/General Relief (GR), etc.)? (Please Check One)

Yes

No

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	STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY							CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	6a. HOUSEHOLD’S INFORMATION
	Complete the following information for all persons in the home that you buy and prepare							Social Security number is optional for
								members not applying for benefits. You
	food with, including you. If applying for noncitizens, please complete question 6b
								must answer the questions below for
	and 6c. If not, go to question 6d.
								each person applying for benefits.
								U.S.
								Citizen or
		Applying			How is the			National
		for benefits		Name	person	Date of	Gender	(4 Check Yes		Social Security
		(4 Check Yes		(Last, First, Middle Initial)	related to	birth	(M or F)	or No)		Number
								If no,
		or No)			you?
								complete
								question 6b
								below
		Yes	No		SELF			Yes	No
		Yes	No					Yes	No
		Yes	No					Yes	No
		Yes	No					Yes	No
		Yes	No					Yes	No

Please list the names of anyone who lives with you that does not buy and prepare food with you:

6b. NONCITIZEN INFORMATION - Complete for those listed in question 6a above who are not citizens and are applying for aid.

				Sponsored?
		Date of Entry	Give one of the following (if known):	(4 Check Yes
				or No)	If yes,
	Name	into U.S.	Passport Number,
				complete
		(If known)	Alien Registration Number, etc.
				question 6c
				below:
			DOCUMENT TYPE:__________________________________________________	Yes	No
			DOCUMENT NUMBER:_______________________________________________
			DOCUMENT TYPE:__________________________________________________	Yes	No
			DOCUMENT NUMBER:_______________________________________________
			DOCUMENT TYPE:__________________________________________________	Yes	No
			DOCUMENT NUMBER:_______________________________________________

6c. SPONSORED NONCITIZEN INFORMATION - Complete for those listed in question 6b above who are sponsored noncitizens and are applying for aid.

Did the sponsor sign an I-864?			Yes	No	If yes, please answer the rest of the question. If the sponsor signed an I-134
then skip this question.
Does the sponsor regularly help with money?				Yes	No If yes, how much? $______________
Does the sponsor regularly help with any of the following (check all that apply)?
rent	clothes	food	other ______________________________________________________________

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

6d. STUDENTS

Is anyone who is applying for benefits including you attending a college or vocational school? (Please Check One) Yes No

If yes, please answer this question. If no, skip to the next question.

	Name of person	Name of school/training	Enrolled status	Are they working?
			(4 Check one)
			Half-time or more	Average work hours per
			Less than half-time
				week:_________
			Number of units:______
			Half-time or more	Average work hours per
			Less than half-time
				week:_________
			Number of units:______

7.UNEARNED INCOME

Do you or anyone you buy and prepare food with get income that does not come from a job (unearned)?

(Please Check One) Yes No

If yes, please answer this question. If no, skip to the next question.

Check all types of unearned income that apply from these examples (there may be others not listed here):

Social Security			Veteran benefits, or Military pension			Lottery/gambling winnings
SSI/SSP			Financial aid (school grants/loans/			Help with rent/food/clothing
Cash aid						Insurance or legal settlements
			scholarships)
CalWORKs/TANF/GA/GR/CAPI			Gift of money			Private disability or retirement
Room and board (from your renter)			Unemployment Insurance/State			Strike benefits
Pension			Disability Insurance (SDI)			Other ________________________
Child/Spousal support			Worker’s compensation			______________________________
Government/railroad disability or
retirement
					How often received?			Expect to
								continue?
Person getting the money?		From where?		How much?		(Once, weekly,
								(4 Check
						monthly, or other)
								Yes or No)
				$				Yes	No
				$				Yes	No
				$				Yes	No
				$				Yes	No

If this income is not expected to continue, please explain:

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Please list all income before taxes or other deductions are taken out (gross income).

Examples of earned income are (these examples can be full-time, temporary, seasonal, or training, and there may be others not listed here):

• Wages	• Commissions		•	Tips		• Salaries		• Work study (students)
								Average	How often	Total gross	Expect to
										earned
						Employer’s			paid?
		Employer’s name					Hourly	hours		income	continue?
Person working									(Once, weekly,
		and address			phone number		rate	per		received	(4 Check
									monthly, or
								week		this	Yes or No)
									other)
										month
							$			$	Yes
											No
							$			$	Yes
											No
							$			$	Yes
											No
							$			$	Yes
											No

If this income is not expected to continue, please explain:

IF YES, WHO?	DATE OF JOB LOSS, QUIT, OR CHANGE	DATE OF LAST PAY
REASON?

Is anyone on strike? (Please Check One)	Yes		No
IF YES, WHO?		DATE WENT ON STRIKE		DATE OF LAST PAY

REASON?

8a. SELF-EMPLOYMENT

Self-employed household members may deduct actual self-employment expenses or take a standard 40% deduction off of self-employment income. If you choose actual expenses, you will need to give the County proof of the expenses.

Person	Date business		Gross	Self-employment expenses
		Type of business and name	monthly
self-employed	started		income	(Please 4 check one)
			$	40% flat rate
				Actual expenses $ ___________
			$	40% flat rate
				Actual expenses $ ___________
			$	40% flat rate
				Actual expenses $ ___________
			$	40% flat rate
				Actual expenses $ ___________
			$	40% flat rate
				Actual expenses $ ___________

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

	Who gives care?				Amount	How often paid?
Who gets care?						(Weekly/monthly,
	(Name and address of provider)				paid?
						other)
			$
			$
			$
			$
Does anyone help your household pay all or part of your child/adult care costs listed above?		Yes			No If yes, complete below:
					Amount	How often paid?
Who gets care?	Who helps pay?					(Weekly/monthly,
					paid?
						other)
				$
				$

10.CHILD SUPPORT PAYMENTS

Are you or anyone you buy and prepare food with legally obligated to pay child support, including back child support?

			Amount	How often paid?
	Who pays child support?	Name of child(ren) for whom child support is paid:		(Weekly/monthly,
			paid?
				other)
			$
			$
	11. HOUSEHOLD EXPENSES
	Are you or anyone you buy and prepare food with responsible for any household expenses?		Yes No

If yes, please answer this question. If no, skip to the next question.

NOTE: Do not enter amounts paid by housing assistance such as HUD or Section 8. The heating and cooling, telephone, other utilities, and the homeless shelter are set allowances and you do not need to fill in the actual amount owed.

		Have			Amount	How often billed?
	Type of expenses	expense?		Who pays?		(weekly/monthly,
					owed
		(Please Check One)				other)
	Rent or house payment	Yes	No		$
	Property taxes and insurance (if billed separately	Yes	No		$
	from rent or mortgage)
	Gas, electric, or other fuel used for heating or
	cooling, such as firewood or propane (if billed	Yes	No
	separately from rent or mortgage)
	Telephone/cell phone	Yes	No
	Homeless Shelter Expense	Yes	No
	Water, sewage, garbage	Yes	No
	Does anyone not in your household help you pay			Who helps pay?	How much?	How often paid?
	for the expenses listed above? (Please Check One)				$
	Yes No If yes, please complete.

Does your household receive, or expect to receive, payment from the Low Income Home Energy Assistance Program (LIHEAP)? Yes No

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

12.MEDICAL EXPENSES:

Are you or anyone you buy and prepare food with an elderly (60 or older) or disabled person that has any out-of-pocket medical

List expenses you expect to have in the near future.

		How often	What type of expense?	Will the household be reimbursed
Name of elderly/disabled person	Amount of	paid?	(Prescriptions, dentures,	for any medical expenses?
	expense	(Weekly/	number of meals for	(By Medi-Cal, insurance,
		monthly, other)	attendant, etc.)	family member, etc.)
				IF YES, BY WHO:
	$
				HOW MUCH: $
				IF YES, BY WHO:
	$
				HOW MUCH: $
				IF YES, BY WHO:
	$
				HOW MUCH: $
				IF YES, BY WHO:
	$
				HOW MUCH: $

• Communal dining facility for the elderly/disabled	• Food distribution program operated	• Other food program
	by a Native American reservation

15.Are you or anyone living with you age 60 or older and unable to buy food and fix meals separately because of a disability? (Please Check One) Yes No

IF YES, WHO?

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

16.HOUSEHOLD’S RESOURCES

Do you or anyone you buy and prepare food with have any resources (cash, money in the bank, Certificate of Deposit, stocks and

bonds, etc.)?	Yes	No If yes, please answer this question. If no, skip to the next question.
Check all that apply:
Bank/Credit Union account (Checking)			Money Market Account	Stocks
Bank/Credit Union account (Saving)			Mutual Funds	Bonds
Safe Deposit box			Certificate of Deposit (CD)	Other: ________________________
Savings Bond(s)			Cash on hand

If joint account with another person please say so below.

For each box checked above, complete the following information.

$

$

$

$

Have you or anyone in your household sold, traded, given away, or transferred a resource in the last three months? Yes No

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

Additional Writing Space

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

Additional Writing Space

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