Statment Of Fact For Food Stamps Form – Fill Out and Use This PDF

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

DEPARTMENT OF HEALTH CARE SERVICES

STATEMENT OF FACTS FOR CASH AID, CalFresh, AND

COUNTY USE ONLY

MEDI-CAL/34-COUNTY MEDICAL SERVICES PROGRAM (CMSP)

CASE NAME

CMSP listed to the left of each question tell you which questions are for each program.

CASE NUMBER

●

Give any proof (such as bills, receipts and records) to support your answers. Tell your worker when

you need help in getting proof or in filling out this form. If you need more space, attach another sheet.

WORKER

DATE RCD

●

If you are asking for CalFresh and you are not an adult member of the household, attach a written

authorization signed by the head of household or other adult member.

CA

1

A.

Person applying, or caretaker relative of child(ren) for whom aid is wanted.

HOME PHONE

CF

NAME:

(

)

MC

HOME ADDRESS (NUMBER, STREET)

MAILING ADDRESS (IF DIFFERENT)

DAYTIME PHONE

■ New

■ Restoration

(

)

■ Redetermine

■ Recertification

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

■ Residency Verified

■ CF ID

CF

B.

Are you homeless?

If “YES”: Are you temporarily staying in someone else’s home?

■ YES ■ NO

■ CF Aged/Disabled Verified

■ YES ■ NO

If “YES”: Give date you began staying at this home:

■ MC ID

CA

C.

Have you received a pay Rent or Quit Notice?

■ YES ■ NO

■ MC Minor Consent: Exempt

2 For each ADULT living in the home, give us all the facts.

from ID, Residency, SSN, Verifs

CA (A) ADULT’S NAME (FIRST, MIDDLE, LAST)

CITIZEN/NONCITIZEN STATUS (✓)

■ U.S. Citizen/National

■ AU

■ NON-AU

■ MFBU

CF

■ Noncitizen:

Sponsored

■ YES

■ NO

CF Non-HH/Excluded

MC

Member Code:

RELATIONSHIP TO APPLICANT OR CARETAKER RELATIVE TO CHILD(REN)

BIRTHDATE (MONTH

DAY

YEAR)

SOCIAL SECURITY NUMBER

Work Registration/Exemption Codes:

WELFARE to WORK

CF

ABAWD

SEX (✓)

BLIND, DEAF OR DISABLED

PREGNANT

BIRTHPLACE

CITY

STATE

COUNTRY

■ M ■ F

■ YES

■ NO

■ YES

■ NO

VERIFIED: ■ Blind/Deaf/Disabled

TYPE OF AID REQUESTED (✓)

MARITAL STATUS (✓)

■ SSN

■ DED Packet

■ Citizen

■ Cash Aid

■ CalFresh

■ None

■ Married

■ Never Married

■ Separated

■ Eligible Noncitizen

■ SAVE

■ Medi-Cal

■ 34-County CMSP

■ Divorced

■ Common Law

■ Widowed

Alien Reg. #

D.O.E.

CA (B) ADULT’S NAME (FIRST, MIDDLE, LAST)

CITIZEN/NONCITIZEN STATUS (✓)

■ U.S. Citizen/National

■ AU

■ NON-AU

■ MFBU

CF

■ Noncitizen:

■ YES

■ NO

CF Non-HH/Excluded

MC

Sponsored

Member Code:

Work Registration/Exemption Codes:

RELATIONSHIP TO APPLICANT OR CARETAKER RELATIVE TO CHILD(REN)

BIRTHDATE (MONTH

DAY

YEAR)

SOCIAL SECURITY NUMBER

WELFARE to WORK

CF

ABAWD

SEX (✓)

BLIND, DEAF OR DISABLED

PREGNANT

BIRTHPLACE

CITY

STATE

COUNTRY

■ M ■ F

■ YES

■ NO

■ YES

■ NO

VERIFIED: ■ Blind/Deaf/Disabled

TYPE OF AID REQUESTED (✓)

MARITAL STATUS (✓)

■ SSN

■ DED Packet

■ Citizen

■ Cash Aid

■ CalFresh

■ None

■ Married

■ Never Married

■ Separated

■ Eligible Noncitizen

■ SAVE

■ Medi-Cal

■ 34-County CMSP

■ Divorced

■ Common Law

■ Widowed

Alien Reg. #

D.O.E.

CA (C) ADULT’S NAME (FIRST, MIDDLE, LAST)

CITIZEN/NONCITIZEN STATUS (✓)

■ U.S. Citizen/National

■

AU

■

NON-AU

■

MFBU

CF

■ Noncitizen:

Sponsored

■ YES

■ NO

CF Non-HH/Excluded

MC

Member Code:

RELATIONSHIP TO APPLICANT OR CARETAKER RELATIVE TO CHILD(REN)

BIRTHDATE (MONTH

DAY

YEAR)

SOCIAL SECURITY NUMBER

Work Registration/Exemption Codes:

WELFARE to WORK

CF

ABAWD

SEX (✓)

BLIND, DEAF OR DISABLED

PREGNANT

BIRTHPLACE

CITY

STATE

COUNTRY

■ M ■ F

■ YES

■ NO

■ YES

■ NO

VERIFIED: ■ Blind/Deaf/Disabled

■ SSN

■ DED Packet

■ Citizen

TYPE OF AID REQUESTED (✓)

MARITAL STATUS (✓)

■ Eligible Noncitizen

■ SAVE

■ Cash Aid

■ CalFresh

■ None

■ Married

■ Never Married

■ Separated

■ Medi-Cal

■ 34-County CMSP

■ Divorced

■ Common Law

■ Widowed

Alien Reg. #

D.O.E.

COUNTY USE ONLY

CF NON-HH/EXCLUDED MEMBER (63-402)

CF WORK/TRAINING EXEMPTIONS (63-407.21)

CF ABAWD EXEMPTIONS (63-410.3)

WtW WORK EXEMPTIONS (42-712)

1.

Separate HH (Purchase/prepare) (.12, .13)

a.

Under 16/60 or older

1.

ABAWD with CF Work/Training

Age under 16

(.41)

2.

Separate HH (Elderly/disabled)

(.17)

a.(1) 16/17 not head of household; or

Exemption Code 63-407.21

School Attendance

(.42)

3.

Roomer (must be listed in 13

)

(.211)

16/17 in school/training at least

2.

Under 18/50 or older

(.321)

Age 60 or older

(.43)

4.

Live-in attendant

(.212)

1/2 time

3.

Pregnant

(.322)

Disability

(.44)

5.

Other shared living quarters

(.213)

NCR caring for dependent or

b.

Mentally/physically unfit for work

4.

Adult living in HH with dep. child

(.323)

6.

Ineligible alien

(.221)

ward of the court or at risk of

c.

Mandatory participant in

5.

Lives in ABAWD exempt area

(.33)

7.

Boarder (must be listed in 13

)

(.3)

FC placement

(.45)

Welfare to Work activities

8.

SSN disqualified

(.222)

Care of another ill or incap

9.

IPV disqualified

(.223)

d.

Cares for child under 6 or

member of the household

(.46)

10. Workfare sanctioned

(.225)

incapacitated person

Care of child:

11. SSI/SSP recipient

(.226)

e.

Applicant for/recipient of UIB

- Age 6 months or under (or as

12. Ineligible student

(.227)

f.

Participant in drug/alcohol program

allowed under county’s

13. Work req. disqualified

(.228)

g.

30 hour week/min. x 30

CalWORKs plan)

(.471)

14. Questionable Citizenship

(300.51(b))

h.

1/2 time student in school, training

- Member (who previously claimed

15. Vol. quit ineligible

(408.1, .2)

or higher education.

.471) upon birth or adoption of

16. Ineligible/disqualified ABAWD

(410.4)

subsequent child(ren)

(.472)

17. Fleeing felon/parole or

probation violator

(.224)

Pregnancy

(.48)

18. Drug felon

(.229)

VISTA-full or part time volunteer (.49)