Cw 42 Form PDF Details

Navigating the complexities of homelessness can be a daunting ordeal, but for those residing in California, the Cw 42 form offers a beacon of hope. This crucial document, facilitated by the California Department of Social Services, serves as a Statement of Facts for those seeking Homeless Assistance. Whether individuals find themselves without a place to stay or facing eviction notices, the form details the possibility of obtaining financial aid to secure temporary or permanent housing. Specifically designed to offer support once every 12 months—except in cases of domestic violence, physical or mental illness, natural disasters, or uninhabitability—the Cw 42 form highlights eligibility criteria, including a resource limit of $100 and either current eligibility for CalWORKs or potential eligibility. Additionally, it outlines the support process, from applying for up to two months of back rent to accessing Temporary Shelter payments for up to 16 days. The form meticulously requires applicants to disclose personal and financial information, prompting a candid declaration of their current living situation, income sources, and assets. It places a significant emphasis on the need for verification, ensuring that aid is directed appropriately and efficiently. Through the Cw 42 form, California aims to provide a structured pathway out of homelessness, emphasizing the importance of seeking permanent housing solutions while offering immediate relief to those in dire need.

QuestionAnswer
Form NameCw 42 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescw42, ca statement of homeless, ca of homeless assistance get, ca of homeless assistance

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATEMENT OF FACTS - HOMELESS ASSISTANCE

Important Information

●If you have no place to stay or have received a pay rent or quit notice from your landlord, you may be able to get Homeless Assistance payments limited to once every 12 months, unless your homelessness is due to an exception. To get Homeless Assistance, you cannot have more than $100 in resources and you must either be eligible for CalWORKs or appear to be eligible for CalWORKs.

●Exceptions to the 12 month limit are homelessness exceptions are also limited to once every 12 months. exception.

due to: domestic violence, physical or mental illness, or uninhabitability of the home. These Homelessness that is directly caused by a State or Federal declared natural disaster is also an

●If you received a pay rent or quit notice you may be able to get Homeless Assistance payments for up to two months of back rent.

●If you have no place to stay, you must be looking for permanent housing to get Homeless Assistance for Temporary Shelter (TS). If you find someplace to live, you may get money for permanent housing.

●You may get TS payments for up to 16 days in a row. The first day starts when you get the first TS payment. If you stay anywhere for free, or somewhere other than a shelter or business which rents rooms, you can’t get a TS payment, but the days count as part of the 16 days.

●To get TS payments you must rent from a person or place that is in the business of renting property.

●At the end of the 16 days, TS will stop. You will not be eligible to receive TS again for another 12 months, unless you have an exception, even if you have not used up all the TS benefits.

●You will be asked to prove that your payments were spent on shelter. If you can’t, future payments will go to a shelter, landlord or others for you.

Instructions: Print all answers in ink. If you need help, ask your worker.

 

 

 

 

COUNTY USE ONLY

 

 

 

 

 

 

 

 

 

1. Name of Caretaker Relative (first, middle, last)

 

 

 

 

DATE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Message Phone

 

Social Security Number

 

Date of Birth

 

CO

Aid

Case Number

AU

A

B

 

Code

 

-

-

 

 

 

 

 

 

 

Mo._____ Day ____ Yr. ____

C

 

 

 

 

 

 

 

 

 

2.What is your current or last address?

 

 

Number, Street

 

City

State

Zip

 

D

Case Name (Last, First)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

Date HA Authorized

 

3. Do you get Cash Aid?

 

 

■ YES ■ NO

 

Mo. _______ Day _______ Yr. _______

 

 

 

 

 

 

If "YES," in which county:

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

F

Type of HA (check)

 

Did you get Homeless Assistance from any county at any time?

 

■ YES ■ NO

 

 

 

 

■ Temporary

■ Permanent

 

 

If "YES," complete:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ TV

■ PV

 

 

Which county:

 

When:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Does anyone in your home get income from a job or training program or any other source?

 

 

 

 

 

■ TM

■ PM

■ YES ■ NO

 

 

 

 

If “YES”, list all income and who gets it below:

 

 

 

 

 

 

 

■ TU

■ PU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ TD

■ PD

 

 

 

 

 

 

 

 

 

 

 

START DATE:________

START DATE:_______

 

 

 

 

 

 

 

 

 

6. List all liquid resources you own (include cash, checks, savings or checking accounts,

 

 

 

 

 

Disposition:

 

 

 

credit union accounts, etc.). List each item and give its value.

 

 

 

 

 

 

■ Shelter arranged prior to TS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Vendor payment issued

7.

If you get Homeless Assistance, you may have the payment made out to you or given directly to a shelter,

 

 

■ HA denied

 

 

 

landlord or other for you. Check (✓) below to tell us how you want the payment made:

 

 

 

 

 

 

 

 

 

 

■ To Yourself

■ To a Landlord

■ To a Shelter

■ Other (explain):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not have a permanent home, fill out questions 8 through 12. If you are asking for back rent, skip to

 

 

 

 

questions 13 through 17.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Worker:

 

8.

Explain where you are staying now.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total resource value:

9.How long have you been there?

10.Do you pay for staying there? If "YES," how much?

11.Explain why you have no place to live.

12. Are you seeking permanent housing?

■ YES ■ NO

Explain:

 

CW 42 (9/16) REQUIRED FORM - SUBSTITUTES PERMITTED

13.What day did you get a pay rent or quit notice?

14.How many months of back rent do you owe?

15.How much is your monthly rent?

16.Why didn’t you pay your rent?

17.Why is your Landlord evicting you?

CERTIFICATION

I understand that:

•Homeless Assistance Temporary Shelter (TS) and Permanent Housing (PH) payments are limited to once every 12 months, unless I have a verified exception.

•There is a limit on how much Homeless Assistance I can get.

•I am required to give my Social Security Number, which will be used to check identity and verify that I am not getting aid in more than one case, one county, or one state.

I understand that I must provide proof that:

•I am homeless; or I have received a notice to pay rent or quit.

•I am homeless due to an exception, if I have already gotten homeless assistance.

•I used the TS payment for housing, and that if I cannot, I must have my homeless assistance payments made out or given to a shelter, landlord or to others for me.

I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained on this Statement of Facts - Homeless Assistance is true and correct.

SIGNATURE OF CARETAKER RELATIVE

DATE

 

 

CW 42 (9/16) REQUIRED FORM - SUBSTITUTES PERMITTED

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Stage # 1 for submitting cw 42 form

2. Soon after the previous part is completed, proceed to enter the suitable details in all these: Total resource value, How long have you been there, Do you pay for staying there, If YES how much, Explain why you have no place to, Are you seeking permanent housing, CW REQUIRED FORM SUBSTITUTES, and YES NO.

Part number 2 of submitting cw 42 form

3. This next part is all about What day did you get a pay rent, How many months of back rent do, How much is your monthly rent, Why didnt you pay your rent, Why is your Landlord evicting you, CERTIFICATION, I understand that, I understand that I must provide, Homeless Assistance Temporary, and I am homeless or I have received a - fill in these empty form fields.

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cw 42 form writing process outlined (part 4)

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