Form CW 42 at a glance
What it is: CW 42 is the California Department of Social Services STATEMENT OF FACTS - HOMELESS ASSISTANCE.
Who signs: The caretaker relative signs at SIGNATURE OF CARETAKER RELATIVE.
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. (checked October 31, 2026)
Exceptions to the 12 month limit are homelessness due to: domestic violence, physical or mental illness, or uninhabitability of the home. These exceptions are also limited to once every 12 months. Homelessness that is directly caused by a State or Federal declared natural disaster is also an exception.
A filled-in Form CW 42 example: a caretaker relative with no place to stay
How to fill out Form CW 42, box by box
Name of Caretaker Relative, Social Security Number and Date of Birth
Print all answers in ink. If you need help, ask your worker.
Enter the Name of Caretaker Relative (first, middle, last).
Enter the Social Security Number.
Enter the Date of Birth as Mo., Day and Yr., and the Message Phone.
What is your current or last address?
Enter your current or last address: Number, Street, City, State, Zip.
Do you get Cash Aid?
Check YES or NO for: Do you get Cash Aid?
If YES, enter in which county.
Did you get Homeless Assistance from any county at any time?
Check YES or NO for: Did you get Homeless Assistance from any county at any time?
If YES, complete Which county and When.
Does anyone in your home get income from a job or training program or any other source?
Check YES or NO for: Does anyone in your home get income from a job or training program or any other source? If YES, list all income and who gets it.
List all liquid resources you own
List all liquid resources you own (include cash, checks, savings or checking accounts, credit union accounts, etc.). List each item and give its value.
Check below to tell us how you want the payment made
If you get Homeless Assistance, you may have the payment made out to you or given directly to a shelter, landlord or other for you.
Check (✓) To Yourself, To a Landlord, To a Shelter or Other (explain) to tell how you want the payment made.
If you do not have a permanent home
If you do not have a permanent home, fill out questions 8 through 12.
Explain where you are staying now.
How long have you been there?
Do you pay for staying there? If "YES," how much?
Explain why you have no place to live.
Are you seeking permanent housing? Check YES or NO, and explain.
If you are asking for back rent
If you are asking for back rent, skip to questions 13 through 17.
What day did you get a pay rent or quit notice?
How many months of back rent do you owe?
How much is your monthly rent?
Why didn't you pay your rent?
Why is your Landlord evicting you?
Certification and signature
You understand that Homeless Assistance Temporary Shelter (TS) and Permanent Housing (PH) payments are limited to once every 12 months, unless you have a verified exception.
You understand that there is a limit on how much Homeless Assistance you can get.
You are required to give your Social Security Number, which will be used to check identity and verify that you are not getting aid in more than one case, one county, or one state.
You must provide proof that you are homeless; or you have received a notice to pay rent or quit.
You must provide proof that you are homeless due to an exception, if you have already gotten homeless assistance.
You must provide proof that you used the TS payment for housing, and that if you cannot, you must have your homeless assistance payments made out or given to a shelter, landlord or to others for you.
You 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.
Sign at SIGN, as SIGNATURE OF CARETAKER RELATIVE, and enter the DATE.
More rules for Form CW 42
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.
Sources
[1] Form CW 42 (9/16), Statement of Facts - Homeless Assistance, California Department of Social Services (the Official source link on this page).