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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NON-ASSISTANCE CALFRESH (NACF) HOUSEHOLD RECERTIFICATION FORM

This form can be used at recertification in lieu of the CalFresh only application for Non-Assistance CalFresh households who are subject to Quarterly Reporting/Prospective Budgeting.

Please fill out the following personal information for the person requesting CalFresh benefits.

Fill out as much of this form as you can, sign on page 5, and return it to your local CalFresh office. We need at least your name, address and signature. If you are without money for food, you may be able to get emergency CalFresh benefits in three (3) days.

You need to try to answer all questions on this recertification form.

NAME (FIRST, MIDDLE, LAST)

CONTACT PHONE:

				(	)
HOME ADDRESS (NUMBER, STREET)			MAILING ADDRESS (IF DIFFERENT)

CITY	STATE	ZIP CODE	CITY	STATE		ZIP CODE

Are you homeless?					■ YES	■ NO
If “YES”, are you temporarily staying in someone else’s home?					■ YES	■ NO
If “YES”, give date you began staying at this home: ________________________

		EXPEDITED BENEFITS

1. Is someone in the household a Migrant/Seasonal Farmworker?					■ YES	■ NO

a.How much is your rent or mortgage this month? $ _____________

b.How much are your utilities this month, if separate from your rent or mortgage? $ _________

c.How much money do you have? This includes money in bank accounts, in your home, or any other place. $ __________

d. Do you have or will you receive any income this month?	■ YES ■ NO
List all your household income below:
NAME OF PERSON WHO GETS MONEY	HOW MUCH EACH MONTH?

	$
	$

Complete A, B & C below. If you don’t complete this section, the county will do it for you. Check all that apply. THIS WILL NOT AFFECT YOUR ELIGIBILITY.

A. ETHNICITY
Are you Hispanic or Latino?	■ YES ■ NO

B.RACE/ETHNIC ORIGIN (Select one or more of the following:)

■ American Indian or Alaskan Native

■ Black or African American

■Asian (If checked, please select one or more of the following)

■	Filipino ■ Chinese ■ Japanese ■ Korean ■ Vietnamese ■ Asian Indian
■	Cambodian ■ Laotian ■ Other Asian (specify) ____________________________

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

■ Native Hawaiian ■ Guamanian ■ Samoan ■ Other (specify) ______________

■ White

C.PRIMARY LANGUAGE

■	English ■ Spanish ■ Lao ■ Tagalog ■ American Sign ■ Cantonese
■	Cambodian ■ Vietnamese ■ Russian ■ Other (specify) _____________________

COUNTY USE ONLY

CF 27 (2/13) RECOMMENDED FORM	PAGE 1 OF 5

2. List all persons living with you, including yourself. Attach a separate sheet of paper if needed.

NAME:		SSN:		DATE OF BIRTH:	RELATIONSHIP:

					HEAD OF HOUSEHOLD

Check all that apply:
■ U.S. Citizen/National ■ Noncitizen	■ Legal Permanent Resident		Sponsored:		■ YES ■ NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

NAME:

SSN:

DATE OF BIRTH:

RELATIONSHIP:

Check all that apply: Do you want this person to have an EBT card to buy food for you?	■
■ U.S. Citizen/National ■ Noncitizen ■ Legal Permanent Resident Sponsored:	■
Do you buy and prepare food with this person?	■

YES YES YES

■

NO NO NO

CF 27 (2/13) RECOMMENDED FORM

PAGE 2 OF 5

3.Does anyone live in any of the following type of facilities or take part in any food program

including those listed below? (check all that apply)	■ YES	■ NO
■ Homeless Shelter	■ Reservation for Native American
■ Correctional Facility	■ Penal Institution
■ Drug/Alcohol Rehabilitation Center	■ Shelter for Battered Women
■ Food Distribution Program	■ Psychiatric Hospital/Mental Institution
If YES, complete the following:

NAME:

NAME OF CENTER/SHELTER/

FOOD PROGRAM ETC.

DATE ENTERED

DATE EXPECTED TO LEAVE

4. Do you pay anyone or does anyone pay you for meals and/or a room?

■ YES

■ NO

If YES, complete the following:

NAME OF PERSON WHO PAYS FOR

NAME OF PERSON WHO

CHECK

HOW

HOW OFTEN?

NUMBER OF

MEALS/ROOM

PROVIDES MEALS/ROOM

ONE: (✔)

MUCH?

MEALS PER DAY

■ Meals

■ Room

■ Both

5. Is anyone 16 years of age or older enrolled in school, college or a training program?

■ YES

■ NO

If YES, complete the following:

NUMBER OF

NAME OF PERSON

NAME OF SCHOOL

ATTENDANCE

UNITS PER

WORKING

SEMESTER/

QUARTER

■ Full time

■ YES

■ NO

■ Half time

Number Of Hours:

■ Other

■ Full time

■ YES

■ NO

■ Half time

Number Of Hours:

■ Other

6. Is anyone in the home unable to buy or fix meals because they are blind, deaf or disabled?

■ YES

■ NO

If YES, complete the following:

NAME

EXPLAIN

7. Is anyone in the home pregnant?

■ YES

■ NO

If YES, complete the following:

NAME

EXPECTED DUE DATE

8. Do you or anyone living in the home have any housing costs?

■ YES

■ NO

If YES, complete the following:

HOW MUCH IS PAID BY

IF SOMEONE ELSE

HOW

HOUSING COST

TOTAL COST

HOW MUCH DO YOU

RENTAL ASSISTANCE

PAYS,

OFTEN

PAY?

PROGRAMS, SUCH AS

HOW MUCH?

BILLED?

HUD, SECTION 8, ETC?

Rent

House (mortgage) payment

Property Taxes

(If not in house payment)

Insurance

(If not in house payment)

Other (explain):

CF 27 (2/13) RECOMMENDED FORM

PAGE 3 OF 5

9a. Does anyone have any utility costs?			■ YES	■ NO
If YES, please check all boxes below that apply.

Gas			Garbage or trash
Electricity			Sewer
Other fuel (such as propane, butane, wood, coal, etc.)			Telephone/other means of communication, such as internet,
			etc.

Water			Other (explain)

9b. Do you use gas, electricity or other fuel for heating or cooling?			■ YES	■ NO
If YES, please check below.
Utility	Used for Heating or Cooling?
Gas	■ YES	■ NO
Electricity	■ YES	■ NO
Other Fuel	■ YES	■ NO

10.Does anyone, including children, have any of the resources listed below? If YES, explain below:

●	Cash or checks	●	Checking or Saving accounts	●
●	Mortgages	●	Oil, mining or mineral rights	●
●	Employee deferred compensation	●	Sales contracts	●
● IRA or Keogh Plans		●	Trust funds
●	Retirement Funds	●	Stocks, Bonds

●Certificate Deposit

■ YES ■ NO

Money Market accounts

Credit Union accounts

Other

TYPE OF RESOURCE		OWNER	CURRENT		AMOUNT OWED		NAME & ADDRESS			ACCOUNT
			VALUE			(IF ANY)		OF BANK		NUMBER


11. Does anyone own or is anyone buying real estate anywhere (in or outside of the United States)?									■ YES	■ NO
If YES, complete the following:
TYPE	ADDRESS OR LOCATION			USED AS:		OWNER:			ESTIMATED VALUE:
				USED AS:
				■ HOME					AMOUNT OWED:
				■ RENTAL					AMOUNT OWED:
				■ RENTAL

TYPE	ADDRESS OR LOCATION			USED AS:		OWNER:			ESTIMATED VALUE:
				■ HOME					AMOUNT OWED:
									AMOUNT OWED:
				■ RENTAL
12a. Is any member of your household avoiding felony prosecution, custody or confinement									■ YES	■ NO
after conviction?									■ YES	■ NO
after conviction?

If YES, explain below:

NAME

EXPLAIN

NAME

EXPLAIN

12b. Has any member of your household been found to be in violation of probation/parole?			■ YES ■ NO
If YES, explain below:

NAME	EXPLAIN	NAME	EXPLAIN

CF 27 (2/13) RECOMMENDED FORM

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13a.Since August 22, 1996, have you or any member of your household been convicted of a drug-related felony that has not been expunged?

If No, go to question #15.
If Yes: _______________________________________________________________	________________________
NAME	DATE CONVICTED

13b.Was the conviction for any of the following:

●Transporting, importing into this state, selling, furnishing, administering, giving away, possessing for sale, purchasing for the purposes of sale, manufacturing, or processing precursors with the intent to manufacture a

controlled substance or cultivating, harvesting, or processing marijuana?	■	YES	■	NO
● Encouraging, inducing, soliciting or intimidating a minor to participate in any of the above activities?	■	YES	■	NO

14.	Have you or any member of your household:
a)	Completed a government recognized drug treatment program?	■ YES	■	NO
b)	Participated in a government recognized treatment program?	■ YES	■	NO
c)	Enrolled in a government recognized drug treatment program?	■ YES	■	NO
d)	Been placed on a waiting list for a government recognized drug treatment program?	■ YES	■	NO
e)	Ceased the use of controlled substances? (Must show proof to your worker)	■ YES	■	NO
	If YES, please explain:_____________________________________________________________________

15.You can authorize someone to act on behalf of the head of household in case of illness or other circumstances.

If you would like to authorize someone, complete below:

NAME OF AUTHORIZED REPRESENTATIVE

ADDRESS

PHONE NUMBER

16. Are you interested in information or a referral for medical coverage (Medi-Cal or Healthy Families)?	■ YES	■ NO

APPLICANT/RECIPIENT CERTIFICATION

I have completed the questions above and read all the information. I understand the new CalFresh rules and penalties apply to my application or reapplication for CalFresh. I understand the new rules and agree to comply with them.

The U.S. Department of Agriculture prohibits discrimination in all its programs and activities on the basis of race, color, sex, reli- gion, national origin, age, disability or political beliefs. You may file a complaint if you think you have been discriminated against. If you disagree with the decision of the county, an appeal process is available to you.

The information on this application may be shared with federal, state and local agencies only for the purposes of certifying eligibility for the CalFresh Program. This process may include confirmation with the U.S. Citizenship and Immigration Services (USCIS, formerly INS) of the immigration status only of those persons seeking CalFresh benefits. Federal law says the USCIS cannot use the information for anything else except cases of fraud.

SIGNATURE

I certify under penalty of perjury under the laws of the United States of America and the State of California that the information I have provided on this application form is true, correct and complete.

Signature (Adult household member or Authorized Representative)

Date

Signature of Witness or Interpreter

Date

Signature of Eligibility Worker

Date

CF 27 (2/13) RECOMMENDED FORM

PAGE 5 OF 5

Question	Answer
Form Name	Cf 27 Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	calfresh recertification requirements, calfresh recertification packet, renew benefit calfresh application, calfresh anual redeternination recertification forms

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