Form Cw 5 PDF Details

The CW 5 form stands as a crucial document within the State of California, specifically designed for the verification and referral of veterans' benefits. Managed by the California Department of Social Services alongside Health and Human Services Agency, it plays an essential role in ensuring veterans and their dependents can access benefits they might be eligible for. It requires detailed information including but not limited to the veteran's Social Security Number, Date of Birth, Military Serial Number, and Veterans Administration Claim Number to determine eligibility and facilitate aid applications. The form further guides on how to coordinate with County Veterans Service Offices for verification of benefits received and to explore potential benefits. This streamlined process not only simplifies the application for assistance but mandates cooperation to prevent denial or discontinuation of aid. With clear sections dedicated to the veteran's personal details, claimant information, authorization for information release, and official use only remarks, the CW 5 form encapsulates a comprehensive approach to veteran welfare, asserting its importance in the veteran benefits verification and referral system.

QuestionAnswer
Form NameForm Cw 5
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCVSO, discontinuance, cw5 veteran, cw5 veteran's referral form

Form Preview Example

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

VETERANS BENEFITS VERIFICATION AND REFERRAL

NOTE: Do not complete this form unless one of the following is known:

 

 

 

 

 

 

 

• Veterans Social Security Number and Date of Birth

You

and any

member

of

your

household for

whom you

are

Military Serial Number

 

 

 

 

 

 

 

 

applying for aid must give us the Social Security Number(s) (SSN).

The

• Veterans Administration (VA) Claim Number

SSN(s) are used to determine your eligibility and failure to cooperate may

result in denial or discontinuance of aid. Authority: 45 Code of Federal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regulations Section 205.52, and Welfare and Institutions Code Section

 

 

 

 

Name and Address of County Veterans Service Office

11268(a).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NUMBER (INCLUDING MEDS AID CODE):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT/RECIPIENT PHONE #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE WORKER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORKER PHONE #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VETERAN’S NAME (LAST, FIRST, MIDDLE)

 

 

BIRTH DATE:

 

 

 

BIRTHPLACE:

 

 

LIVING?

IF DECEASED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

DATE OF DEATH:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PLACE OF DEATH:

 

VETERAN’S ADDRESS: (NUMBER, STREET, CITY, STATE, ZIP CODE)

 

 

 

 

 

 

 

 

 

DOES THIS VETERAN

VA CLAIM NUMBER:______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIVE IN YOUR HOME?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER:______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILITARY SERIAL NUMBER:_______________________________

 

 

 

 

 

 

 

 

 

 

 

BRANCH OF SERVICE:

 

 

 

DATE OF ENTRY:

 

DATE OF DISCHARGE:

TYPE OF DISCHARGE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HONORABLE GENERAL

MEDICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER THAN HONORABLE

UNKNOWN

 

VETERAN’S MARITAL STATUS:

 

IS THIS VETERAN PERMANENTLY UNABLE TO WORK BECAUSE OF DISABILITY?

DID THIS VETERAN SUFFER AN IN-SERVICE UNJURY OR

 

SINGLE

 

 

 

MARRIED

DIVORCED

 

 

 

 

 

 

 

 

 

 

 

 

 

ILLNESS THAT CAUSES A CURRENT DISABILITY:

 

 

 

 

YES

NO

 

 

 

 

 

YES

NO

 

 

 

SEPARATED

 

 

 

WIDOWED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS ANYONE IN LONG-TERM CARE:

 

 

IS ANYONE BLIND, OR IS HOME CARE NEEDED TO FEED, BATHE, OR DRESS A HOUSEHOLD

VETERAN’S GROSS MONTHLY INCOME:

$

YES

NO IF YES, () BELOW:

 

MEMBER:

YES

 

NO IF YES, () BELOW:

 

 

 

 

 

 

 

 

SPOUSE’S GROSS MONTHLY INCOME:

$

VETERAN SPOUSE OTHER

 

VETERAN SPOUSE

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II

NAME OF CLAIMANT:

RELATIONSHIP TO VETERAN: BIRTH DATE:

SOCIAL SECURITY NUMBER:

ADDRESS:

SECTION III

I hereby authorize the welfare department to release the above information to the County Veterans Service Office and the Veterans Administration for purposes of identifying or obtaining benefits available to the persons identified above. I also authorize the County Veterans Service Office and Veterans Administration to release their findings (to be noted below).

SIGNATURE (OR MARK) OF VETERAN/DEPENDANT:

DATE:

SIGNATURE OF WITNESS TO MARK:

DATE:

SECTION IV (To be completed by the County Welfare Department and the County Veterans Service Office)

The County Welfare Department requests the County Veterans Service Office to:

Verify any VA benefits received by the veteran and/or dependent(s):

Determine veteran/dependent’s eligibility for veteran’s benefits:

 

1-Veteran

2-Claimant

3-Claimant

4-Claimant

Monthly Benefit

 

 

 

 

$

$

$

$

 

Beginning Date

 

 

 

 

(Month/Day/Year)

 

 

 

 

Ending Date

 

 

 

 

(Month/Day/Year)

 

 

 

 

Lump Sum Payment

$

$

$

$

(Past 6 Months)

 

 

 

 

() If monthly benefit is paid,

() Eligibility status:

Compensation

No basic eligibility

Pension

Claim initiated

Other (see remarks)

Claim being reviewed

Includes A & A benefits of $__________

Claim denied

REMARKS: (For official use only)

Name and Address of County Human Services Office

CW 5 (7/01) REQUIRED FORM - NO SUBSTITUTE PERMITTED

CVSO REPRESENTATIVE: (PRINT)

PHONE #:

DATE:

INSTRUCTIONS FOR COUNTY USE AND COMPLETION OF

VETERAN’S BENEFITS VERIFICATION AND REFERRAL FORM CW 5

USE THE CW 5:

1.To verify the status amount of the veteran’s benefits being received.

2.To refer applicants or recipients to the County Veterans Service Office (CVSO).

3.To obtain new veteran benefits when the information on the Statement of Facts forms for the following programs indicates possible eligibility for benefits or county general assistance or relief:

California Work Opportunity and Responsibility to Kids (CalWORKs)

Medi-Cal

State-Run County Medical Services Program

Food Stamps

AFDC-Foster Care

Kin GAP

Healthy Families

Other Program Statement of Facts forms

DO NOT COMPLETE THIS FORM IF THE SERVICE PERSON IS STILL ON ACTIVE DUTY, OR NONE OF THE FOLLOWING INFORMATION IS KNOWN:

1.Veteran’s Social Security Number (SSN) and Date of Birth;

2.Veteran’s Military Serial Number;

3.Veterans Administration (VA) Claim Number.

If either of the above applies, do not initiate a CW 5. or the MC 210 or the “ELIGIBILITY WORKER ONLY”: place the form in the case file.

Do make an entry in the “County Use Only” section of the SAWS 2 section of the FC 2 form stating why a referral was not made and

INSTRUCTIONS FOR COMPLETION OF CW 5:

1.Enter name and address of County Veterans Service Office (CVSO) in upper left-hand corner of the address box.

2.Enter name and address of County Welfare Department (CWD) in lower left-hand address box.

3.Check the appropriate request box to verify or determine benefits.

4.Enter worker and applicant/recipient case information in upper right-hand box.

Section I - Have applicant enter all known veteran and, if applicable, claimant information. At least one is required:

(a) Veteran’s SSN and date of birth, (b) Veteran’s military serial number, or (c) VA claim number.

Section II - Have applicant enter all claimant information.

Section III - Have the veteran, dependent/claimant of foster care representative read, sign and date the authorization statement (attach a copy of placement order in foster care cases).

Section IV - This section will be filled in by the CVSO.

DISTRIBUTION AND FILING OF THE CW 5:

Complete original and photocopy 5 copies of the form. Distribute as follows:

Original and 3 copies to CVSO. Have the veteran, dependent/claimant, or foster care representative hand carry 4 copies of the form along with medical documents, military papers, etc, to the CVSO. Referral by mail may be used if hand carry method is not possible.

One copy for case file to be retained until original is completed and returned to CWD by CVSO. CWD will keep the completed original CW 5 as a permanent record and discard the copy.

A copy of the completed original will be kept by CVSO.

If Veterans Affairs Aid and Attendance Benefits have been granted to the veteran, widow or parent of the veteran, CVSO will also send a copy of the completed original to: Department of Health Services, Recovery Branch, Health Insurance Unit 105, P.O. Box 1287, Sacramento, CA 95806.

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How to complete cw5 veteran's referral form part 1

2. Just after the last selection of blank fields is completed, go on to type in the suitable information in all these: SPOUSES GROSS MONTHLY INCOME, SECTION II NAME OF CLAIMANT, VETERAN, NO IF YES SPOUSE, OTHER, VETERAN, SPOUSE, OTHER, RELATIONSHIP TO VETERAN BIRTH DATE, SOCIAL SECURITY NUMBER, ADDRESS, SECTION III I hereby authorize the, SIGNATURE OF WITNESS TO MARK, DATE, and DATE.

Writing section 2 in cw5 veteran's referral form

People frequently get some points incorrect while filling in SECTION II NAME OF CLAIMANT in this section. You should definitely revise everything you type in right here.

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