CW 8A Form PDF Details

When a new child arrives in a household, families navigating the complexities of state aid in California encounter the CW 8A form, a critical step for receiving benefits for children under age 16. This form, designated by the State of California Health and Human Services Agency and managed by the California Department of Social Services, serves as a supplemental application for those seeking cash aid or CalFresh (food assistance) for an additional child. It requires detailed information about the child, including but not limited to their name, social security number, citizenship status, and any sources of income. The form plays a pivotal role not just in extending aid but also in ensuring that all children under the legal guardianship or care of the applicant are appropriately accounted for and receive the necessary support. Additionally, it tackles other significant areas related to the child's welfare, such as their health insurance status, potential income resources, and school attendance, highlighting the form's comprehensive nature in assessing a child's needs. Moreover, the form comes with sections dedicated to specific situations like whether the child is a foster child, their immunization status, and if they have any disabilities, ensuring a tailored approach to each child's unique circumstances. Filling out the CW 8A form accurately is crucial, as it not only impacts the eligibility and level of support received but also entails legal responsibilities, underscored by the certification section that must be signed under penalty of perjury, reinforcing the serious nature of the information provided.

QuestionAnswer
Form NameCW 8A Form
Form Length2 pages
Fillable?Yes
Fillable fields192
Avg. time to fill out38 min 58 sec
Other namescw 8a, county of san diego cw 8a spanish form, cw8a, cw 8a county of san diego

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATEMENT OF FACTS TO ADD A CHILD UNDER AGE 16

(Supplemental Application and Request for Cash Aid and/or CalFresh)

INSTRUCTIONS:

Fill out this form for a new child in the home and sign the Certification section.

If you need more space, attach another sheet of paper. Use one form for each child.

If you get Cash Aid, and you want aid for the new child, this form must be

 

 

 

 

 

filled out by the parent or California domestic partner or adult caretaker relative.

CHILD NEEDS AID DUE

 

For CalFresh households which do not get or want to get Cash Aid, this form

TO PARENT’S

 

 

 

(✔) BELOW

UNEMPLOYMENT

 

2. Give us all the facts for this child.

 

 

 

DEATH

DISABILITY

ABSENCE

 

must be filled out by an adult household member or authorized representative.

 

 

 

 

 

1. Parent’s or Caretaker Relative’s Name

 

Phone

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHILD’S NAME (FIRST, MIDDLE, LAST)

 

PARENT OR CARETAKER RELATIVE’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

SEX (✔)

OTHER PARENT’S NAME

 

 

 

 

 

 

■M ■ F

BIRTHPLACE (CITY/STATE/COUNTRY)

BIRTHDATE (MONTH, DAY, YEAR)

BLIND, DEAF, OR DISABLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ YES ■ NO

 

TYPE OF AID REQUESTED (✔)

 

CITIZEN/NONCITIZEN STATUS (✔)

■ U.S. Citizen/National

 

■ Cash Aid

■ CalFresh

 

■

Noncitizen: Sponsored

■ YES

■ NO

 

 

 

 

 

 

 

 

RELATIONSHIP TO APPLICANT OR TO THE CHILD’S CARETAKER RELATIVE

 

 

IF CHILD IS UNDER AGE 6, ARE IMMUNIZATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHOTS UP TO DATE?

 

 

 

 

 

 

 

 

 

 

 

 

 

■ YES

■ NO ■ Not under age 6

 

3. Is the child a foster child?

 

 

 

 

 

 

 

 

 

 

■ YES ■ NO

 

A. Was the child placed in your home under a dependency order from the

■ YES ■ NO

 

court?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Do you want the foster child and foster care income counted on the

 

 

■ YES ■ NO

 

CalFresh case?

 

 

 

 

 

 

 

 

 

 

 

C. Is the child enrolled in a health care plan?

 

 

 

 

 

 

 

 

■ YES ■ NO

 

4. Did the child get cash aid or CalFresh this month?

 

 

 

 

 

■ YES ■ NO

 

If “YES”, complete below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF AID

 

 

 

 

WHERE (County, State)

 

 

 

 

■ Cash Aid

■ CalFresh

 

 

 

 

 

 

 

 

 

 

 

 

5. Does the child get or expect to get any income, such as:

 

 

 

 

 

■ YES ■ NO

 

Earnings, Supplemental Security Income/State Supplementary

 

 

 

 

Payment (SSI/SSP), Social Security Benefits, Child Support, Foster

 

 

 

 

Care Payment, Veterans Benefits, etc. If “YES”, complete below:

 

 

 

 

 

 

AMOUNT (Before Deductions, if any)

 

 

 

 

 

 

 

 

TYPE OF INCOME

 

 

 

WHEN

 

 

HOW OFTEN

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

Will this income continue? ■ YES ■ NO

If “NO”, explain any known changes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. A. Is the child pregnant or a teen parent?

 

 

 

 

 

 

 

 

■ YES ■ NO

 

If “YES”, Check (✔) status:

■ Pregnant

■ Teen Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOOL STATUS, CHECK (✔)

 

 

 

 

 

 

 

 

 

 

 

 

■ Has a High School Diploma

■ Has a GED

 

 

 

■ Not Attending School (explain):

 

■ Currently Attending School

■ Other (explain):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Has the child received a cash bonus or sanction, or help with child care,

■ YES ■ NO

 

transportation, etc, from the Cal-Learn Program?

 

 

 

 

 

 

If “YES”, complete below:

 

 

 

 

 

 

 

 

 

 

 

 

WHERE (COUNTY)

 

 

 

 

 

 

DATE(S) RECEIVED

 

 

 

 

 

 

■ YES ■ NO

 

7. Has the parent(s) of this child been in the United States (U.S.) military?

 

If “YES”, complete below:

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PARENT

 

PARENT A U.S. CITIZEN

BRANCH OF SERVICE

 

DATES OF SERVICE

HONORABLE DISCHARGE

 

 

 

■ YES ■ NO

 

 

 

 

 

 

 

 

 

■ YES ■ NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.Complete below if you want CalFresh for this child and the child is not a citizen of the U.S. A. How many years total has this child and/or his/her parents lived in the U.S.?

B.While living in the U.S., in how many of the years did this child and/or the child’s parents earn money by working in the U.S.?

C.While living outside the U.S., how many total years did this child and/or the child’s parents work in the U.S. or for a U.S. company?

COUNTY USE ONLY

CASE NAME

CASE NUMBER

WORKER NAME AND NUMBER

DATE RECEIVED

AU

Non-AU

MFG Child

 

 

CF Non-HH

 

 

 

■ Yes

 

 

Excl. Member

 

 

 

■ No

 

 

Code:

Work Registration/Exemption Codes:

WtW:

 

 

 

CF:

 

 

 

 

 

 

 

 

 

 

 

 

 

VERIF:

■ Blind/Deaf/Disabled

■ SSN

■ Citizen

■ SAVE

■Eligible Noncitizen

■ Immun.

Alien Reg. No.

 

D.O.E.

 

 

 

 

 

 

 

 

 

3A. ■ Request dependency order

3B. ■ CA and FC Elig/CR Chooses: Child: ■ CA ■ FC

CR: ■ CA ■ None ■ Kin-GAP

3C. ■ Medi-Cal ■ Fee for Service

■Verification provided

■Verification provided

■FC Income Counted on

CF Case ■ YES ■ NO

■CA Eligible for Higher MAP

Income

(✔) if exempt

Unearned

Earned

CA

CF

 

 

 

 

Verified:

■Referred to Cal-Learn Program

■CW 25

■QR 25A

CW 5■ YES ■ NO Date Initiated ___________________

CF: Honorable

■ YES ■ NO

Discharge

 

CW 8A (12/14) RECOMMENDED FORM

PAGE 1 OF 2

 

9.

 

Does the child own any property or have resources, such as: cash,

■ YES

■ NO

 

COUNTY USE ONLY

 

 

 

 

 

 

 

 

 

 

land, bank accounts, trust funds, savings bonds, Native American

 

 

 

 

 

■ Verification provided

 

 

 

 

per capita payments or trust funds, or other items? If “YES”, complete below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ CA Restricted Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF RESOURCE

ACCOUNT/POLICY

NAME, ADDRESS OF BANK, ETC.

 

 

CURRENT

 

 

 

 

 

 

 

 

 

NUMBER

 

 

 

VALUE

 

 

 

 

 

 

 

 

 

 

 

(✔) Check if exempt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

■ CA

■ CF

 

 

10.

 

Does the child have Medicare or health insurance, such as Blue Cross,

■ YES

■ NO

■ Verification provided

 

 

 

 

Kaiser, CHAMPUS, etc., which is paid for by a parent or parent’s employer?

 

 

 

 

 

Health Coverage Code:

 

 

 

 

If “YES”, list insurance coverage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

If the child has been charged as an adult with a felony, is the child hiding

■ YES

■ NO

 

 

 

 

 

 

 

or running from the law to avoid prosecution, being taken into custody, or

 

 

 

 

 

 

 

 

 

 

 

 

going to jail for that felony crime or attempted felony crime?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

 

Has the child been found by a court of law to be in violation of probation

■ YES

■ NO

 

 

 

 

 

 

 

or parole?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

 

A. If you can get cash aid, eligible members of your family under age 21

 

 

 

 

 

■ CHDP brochure and explanation

 

 

 

 

may be able to get some health examinations through the Child Health

 

 

 

 

 

given

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

and Disability Prevention Program (CHDP).

 

 

■

CHDP Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Do you want more facts about CHDP services?

 

 

 

 

■

Date:

 

 

 

 

.........................................• Do you want free CHDP medical or dental services?

 

 

 

 

 

 

 

 

 

 

 

.....• Do you need help making appointments or getting to the doctor or dentist?

 

 

 

 

■ Referred for Immunization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Do you want more facts about immunization services?

 

 

 

 

■ Other services referral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Do you want facts about non-discrimination, alcohol/drug counseling, past

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Pregnant

 

 

 

 

medical expenses, and other special needs?

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Parent or Guardian of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Does anyone who is pregnant need to find a doctor, get medical transportation,

 

 

child under 5

 

 

 

 

and/or other help?

 

 

 

 

 

 

■ Breastfeeding ■ Postpartum

 

 

 

 

 

 

 

 

 

 

 

 

■ WIC referral

 

 

 

 

E. Is anyone breastfeeding a child?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Family Planning info given

 

 

 

 

If “YES”, was the birth within the last 12 months?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Referred:

 

 

 

 

 

 

 

 

 

 

 

 

 

F.Do you want to get facts or services from a Family Planning Clinic to help you plan your family size and prevent unplanned pregnancies? ....................................

CERTIFICATION

I understand that:

•If I give wrong facts or fail to report all facts or situations on purpose that affect my eligibility and aid payments, I may be fined, jailed/imprisoned, or both. I can be fined up to $10,000 for cash aid and $250,000 for CalFresh. I can be sent to jail/prison for up to 3 years for cash aid and 20 years for CalFresh. And benefits for cash aid and CalFresh can be stopped for 6 months, 12 months, 2 years, 4 years, 5 years, 10 years, 20 years or forever; and for Refugee Cash Assistance, 3 months and 6 months.

•My case can be picked for reviews to prove eligibility; and I must cooperate fully with county, state, and federal personnel in any quality control review.

•The facts I give will be checked out by local, state, and federal personnel.

•The county will send facts to the U.S. Citizenship and Immigration Services (USCIS) for proof of immigration status.

•The facts the county gets from USCIS may affect eligibility for cash aid and CalFresh.

•The facts I give will be checked with tax, welfare, employment agencies, school districts, and the Social Security Administration to prove the child’s eligibility for cash aid and/or CalFresh and to prove that I am getting the right amount of cash aid or CalFresh. And the social security number will be matched with law enforcement agency records for arrest warrants.

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 is true, correct, and complete.

WHO MUST SIGN THIS FORM: For Cash Aid, you and your aided spouse, Registered Domestic Partner, or the other parent (of cash aided children), if living in the home.

For CalFresh, an adult household member or authorized representative.

SIGNATURE OF CARETAKER RELATIVE AND/OR ADULT CALFRESH HOUSEHOLD MEMBER OR AUTHORIZED REPRESENTATIVE

DATE

SIGNATURE OF CASH-AIDED SPOUSE OR DOMESTIC PARTNER OR OTHER PARENT (OF CASH-AIDED CHILD) IF LIVING IN THE HOME

DATE

SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM

DATE

COUNTY USE ONLY

■

INELIGIBLE (Reason)

 

 

 

IMMUNIZATION

 

 

 

■ Informing

 

 

 

 

 

 

 

 

 

 

 

 

(CW 101 /

■

ELIGIBLE

Eligibility Conditions Met - Date:

Authorization Date:

Effective Date of Aid:

TEMP CW 101A)

 

 

 

 

 

 

Regs Met: ■ YES ■ NO

 

 

 

 

 

 

Signature of County Worker

 

Date

Signature of Supervisor

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CW 8A (12/14) RECOMMENDED FORM

PAGE 2 OF 2

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2. The next part is to submit the next few blank fields: Will this income continue YES NO, A Is the child pregnant or a teen, If YES Check status Pregnant, YES NO, SCHOOL STATUS CHECK Has a High, Has a GED Other explain, Not Attending School explain, B Has the child received a cash, transportation etc from the, WHERE COUNTY, DATES RECEIVED, YES NO, Has the parents of this child, YES NO, and If YES complete below.

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3. Within this part, look at Does the child own any property, land bank accounts trust funds, TYPE OF RESOURCE, ACCOUNTPOLICY, NUMBER, NAME ADDRESS OF BANK ETC, Does the child have Medicare or, Kaiser CHAMPUS etc which is paid, YES NO, COUNTY USE ONLY, CURRENT, VALUE, YES NO, Verification provided CA, and Check if exempt CA. These should be filled in with greatest attention to detail.

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As for TYPE OF RESOURCE and Does the child have Medicare or, ensure you don't make any mistakes here. These two are certainly the key ones in the PDF.

4. All set to begin working on this fourth portion! Here you will have all these andor other help Is anyone, F Do you want to get facts or, plan your family size and prevent, CERTIFICATION, Breastfeeding Postpartum WIC, Date Referred, I understand that, If I give wrong facts or fail to, My case can be picked for reviews, The facts I give will be checked, I declare under penalty of perjury, WHO MUST SIGN THIS FORM For Cash, children if living in the home For, SIGNATURE OF CARETAKER RELATIVE, and DATE blank fields to fill out.

county of san diego cw 8a spanish form completion process described (portion 4)

5. As you get close to the final parts of this document, there are actually a couple extra points to complete. Mainly, SIGNATURE OF CASHAIDED SPOUSE OR, DATE, SIGNATURE OF WITNESS TO MARK, DATE, INELIGIBLE Reason, COUNTY USE ONLY, ELIGIBLE, Eligibility Conditions Met Date, Authorization Date, Effective Date of Aid, IMMUNIZATION Informing, CW TEMP CW A, Regs Met YES NO, Signature of County Worker, and Date must be filled out.

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