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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
STATEMENT OF FACTS FOR CASH AID, CalFresh, AND		COUNTY USE ONLY
MEDI-CAL/34-COUNTY MEDICAL SERVICES PROGRAM (CMSP)		CASE NAME

●Fill in the answers to all questions about the benefit(s) you are asking for. Print all answers in ink. The "CA" for Cash Aid, "CF" for CalFresh (formerly called Food Stamps), and "MC" for Medi-Cal/34-County

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.

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

HOME PHONE

NAME:

(

)

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

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

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

■ Noncitizen:

SPONSORED ■ YES

■ NO

PARENT’S (CHECK

(✔) BELOW)

SOCIAL SECURITY NUMBER

SEX (✔)

BIRTHDATE OR DUE DATE

AGE OF CHILD

(Month, Day, Year)

■ M ■ F

UNEMPLOYMENT

DEATH

DISABILITY

ABSENCE

IF YES, NAME OF SCHOOL:

BIRTHPLACE (CITY/STATE/COUNTRY)

PREGNANT

ARE IMMUNIZATIONS UP

BLIND, DEAF

■ YES ■ NO

TO DATE?

OR DISABLED?

■

YES ■ NO

■ YES ■ NO

IS THIS CHILD CURRENTLY ENROLLED IN SCHOOL? (✔)

■ YES

■ NO

TYPE OF AID REQUESTED

■ Cash Aid

MOTHER’S NAME

■ CalFresh

■

Medi-Cal

■ None

RELATIONSHIP TO APPLICANT OR TO

IS CHILD LIVING IN YOUR HOME

FATHER’S NAME

THE CHILD’S CARETAKER RELATIVE

NOW?

■

YES

■

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

CITIZEN/NONCITIZEN STATUS (✔) ■ U.S. CITIZEN/NATIONAL

CHILD NEEDS AID

BECAUSE OF

■ NONCITIZEN:

SPONSORED ■ YES

■ NO

PARENT’S (CHECK

(✔) BELOW)

SOCIAL SECURITY NUMBER

SEX (✔)

BIRTHDATE OR DUE DATE

AGE OF CHILD

(Month, Day, Year)

■ M ■ F

UNEMPLOYMENT

DEATH

DISABILITY

ABSENCE

IF YES, NAME OF SCHOOL:

BIRTHPLACE (CITY/STATE/COUNTRY)

PREGNANT

ARE IMMUNIZATIONS UP

BLIND, DEAF

■ YES ■ NO

TO DATE?

OR DISABLED?

■

YES ■ NO

■ YES ■ NO

IS THIS CHILD CURRENTLY ENROLLED IN SCHOOL? (✔)

■ YES

■ NO

TYPE OF AID REQUESTED

■ Cash Aid

MOTHER’S NAME

■ CalFresh

■

Medi-Cal

■ None

RELATIONSHIP TO APPLICANT OR TO

IS CHILD LIVING IN YOUR HOME

FATHER’S NAME

THE CHILD’S CARETAKER RELATIVE

NOW?

■

YES

■

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

CITIZEN/NONCITIZEN STATUS (✔) ■ U.S. CITIZEN/NATIONAL

CHILD NEEDS AID

BECAUSE OF

■ NONCITIZEN:

SPONSORED ■ YES

■ NO

PARENT’S (CHECK

(✔) BELOW)

SOCIAL SECURITY NUMBER

SEX (✔)

BIRTHDATE OR DUE DATE

AGE OF CHILD

(Month, Day, Year)

■ M ■ F

UNEMPLOYMENT

DEATH

DISABILITY

ABSENCE

IF YES, NAME OF SCHOOL:

BIRTHPLACE (CITY/STATE/COUNTRY)

PREGNANT

ARE IMMUNIZATIONS UP

BLIND, DEAF

■ YES ■ NO

TO DATE?

OR DISABLED?

■

YES ■ NO

■ YES ■ NO

IS THIS CHILD CURRENTLY ENROLLED IN SCHOOL? (✔)

■ YES

■ NO

TYPE OF AID REQUESTED

■ Cash Aid

MOTHER’S NAME

■ CalFresh

■

Medi-Cal

■ None

RELATIONSHIP TO APPLICANT OR TO

IS CHILD LIVING IN YOUR HOME

FATHER’S NAME

THE CHILD’S CARETAKER RELATIVE

NOW?

■

YES

■

CA (D) CHILD’S NAME (FIRST, MIDDLE, LAST)

CITIZEN/NONCITIZEN STATUS (✔) ■ U.S. CITIZEN/NATIONAL

CHILD NEEDS AID

BECAUSE OF

■ NONCITIZEN:

SPONSORED ■ YES

■ NO

PARENT’S (CHECK

(✔) BELOW)

SOCIAL SECURITY NUMBER

SEX (✔)

BIRTHDATE OR DUE DATE

AGE OF CHILD

(Month, Day, Year)

■ M ■ F

UNEMPLOYMENT

DEATH

DISABILITY

ABSENCE

IF YES, NAME OF SCHOOL:

BIRTHPLACE (CITY/STATE/COUNTRY)

PREGNANT

ARE IMMUNIZATIONS UP

BLIND, DEAF

■ YES ■ NO

TO DATE?

OR DISABLED?

■

YES ■ NO

■ YES ■ NO

IS THIS CHILD CURRENTLY ENROLLED IN SCHOOL? (✔)

■ YES

■ NO

TYPE OF AID REQUESTED

■ Cash Aid

MOTHER’S NAME

■ CalFresh

■

Medi-Cal

■ None

RELATIONSHIP TO APPLICANT OR TO

IS CHILD LIVING IN YOUR HOME

FATHER’S NAME

THE CHILD’S CARETAKER RELATIVE

NOW?

■

YES

■

COUNTY USE ONLY

AU	NON-		CF Non-HH/Excluded
AU	AU	MFBU MFG	Member Code:
(✔)	(✔)	(✔) CHILD	Member Code:

	■YES ■ MC: not in home,
	■ NO		18-21 & tax dep.
■ CW 2.1	Alien Reg. #			D.O.E.
CW 371
Work Registration/Exemption Codes:
Welfare-to-Work			CF


Verified:	■ Age ■ Deprivation ■ SSN
■ Blind/Deaf/Disabled		■ DED Packet

■Citizen ■ Eligible Noncitizen ■ SAVE

■Immunization ■ School Attendance

AU	NON-		CF Non-HH/Excluded
AU	AU	MFBU MFG	Member Code:
(✔)	(✔)	(✔) CHILD	Member Code:

	■YES ■ MC: not in home,
	■ NO		18-21 & tax dep.
■ CW 2.1	Alien Reg. #			D.O.E.
CW 371
Work Registration/Exemption Codes:
Welfare-to-Work			CF


Verified:	■ Age ■ Deprivation ■ SSN
■ Blind/Deaf/Disabled		■ DED Packet

■Citizen ■ Eligible Noncitizen ■ SAVE

■Immunization ■ School Attendance

AU	NON-		CF Non-HH/Excluded
AU	AU	MFBU MFG	Member Code:
(✔)	(✔)	(✔) CHILD	Member Code:

	■YES ■ MC: not in home,
	■ NO		18-21 & tax dep.
■ CW 2.1	Alien Reg. #			D.O.E.
CW 371
Work Registration/Exemption Codes:
Welfare-to-Work			CF


Verified:	■ Age ■ Deprivation ■ SSN
■ Blind/Deaf/Disabled		■ DED Packet

■Citizen ■ Eligible Noncitizen ■ SAVE

■Immunization ■ School Attendance

AU	NON-		CF Non-HH/Excluded
AU	AU	MFBU MFG	Member Code:
(✔)	(✔)	(✔) CHILD	Member Code:

	■YES ■ MC: not in home,
	■ NO		18-21 & tax dep.
■ CW 2.1	Alien Reg. #			D.O.E.
CW 371
Work Registration/Exemption Codes:
Welfare-to-Work			CF


Verified:	■ Age ■ Deprivation ■ SSN
■ Blind/Deaf/Disabled		■ DED Packet

■Citizen ■ Eligible Noncitizen ■ SAVE

■Immunization ■ School Attendance

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

List any parent(s) of the child(ren) or unborn who does not live in the home with you.

COUNTY USE ONLY

NAME OF PARENT

REASON THE PARENT DOES NOT LIVE IN THE HOME

■

Verif. on File

■

MC 13

Has anyone changed citizenship/immigration status in the last 12 months?

■ YES ■ NO

If "YES", complete below:

NAME

WHAT CHANGED

DATE

ALIEN NUMBER (IF APPLICABLE)

Is a foster child living in the home?

YES

If "YES", who:

6B: ■ Request dependency

Was the child(ren) placed in your home under a dependency order from the

court?

order

Do you want the foster child(ren) and foster care income counted on the

6C: ■ CA and FC elig/CR chooses:

CalFresh case?

Child: ■ CA

■ FC

CR ■ CA ■ None ■ Kin-GAP

Is the child(ren) enrolled in a health care plan?

6D: ■ Medi-Cal

■ Fee for Service

Has anyone ever used any other name (maiden, adoptive, etc.)?

■ YES ■ NO

If "YES", complete below:

NAME

OTHER NAME(S) USED

NAME

OTHER NAME(S) USED

YES

Calif. Resident:

■ YES ■ NO

Does everyone live in California?

If "NO", explain:

Does everyone plan to stay in California permanently?

■

Property

Does anyone own, lease or maintain a home outside California?

■

Is anyone currently getting public assistance outside California?

If "YES", explain:

E. Is anyone planning to leave California for more than 30 days?

Are you 18 to 21 years of age and claimed as a dependent for income tax purposes?

■ YES ■ NO

■

Tax Dependent Letter Sent

If Yes, who:

■

CA 2.1

Has anyone’s cash aid or CalFresh/SNAP benefits been stopped due to:

■ YES ■ NO

non-cooperation during a quality control review, work or training sanctions or

failure to meet the CalFresh Able Bodied Adults Without Dependent (ABAWD)

work requirement, or for any other reason?

If "YES", explain below:

NAME

WHY

WHEN

WHAT COUNTY/STATE

Has anyone's cash aid or CalFresh been stopped for a period of time or forever

■ YES ■ NO

due to welfare fraud or a CalFresh Intentional Program Violation?

If "YES", explain below:

NAME

WHY

WHEN

WHAT COUNTY/STATE

Does anyone living with you buy food and fix meals separately from

■ YES ■ NO

Separate household eligible:

others in the home?

■ YES ■ NO

If "YES", who:

Is anyone living with you age 60 or older and unable to buy food and

■ YES ■ NO

Separate household eligible:

fix meals separately because of a disability?

■ YES ■ NO

If "YES", who:

Page 3 of 14

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 4 of 14

Do you pay someone else for meals and/or a room?

■ YES ■ NO

COUNTY USE ONLY

If "YES", complete below:

Household Elects

ROOMER

NAME OF PERSON YOU PAY

CHECK (✔)

HOW MUCH

HOW OFTEN

NO. OF MEALS

■ Meals

■ Room

■ Both

PER DAY

BOARDER

HH MEMBER

Does anyone pay you for meals and/or a room?

■ YES ■ NO

If "YES", complete below:

NAME OF PERSON WHO PAYS YOU

CHECK (✔)

HOW MUCH

HOW OFTEN

NO. OF MEALS

PER DAY

■ Meals

■ Room

■ Both

Does anyone get food from any of the following programs?

■ YES ■ NO

• Communal dining facility for the elderly or disabled

• Food distribution program operated by a Native American reservation

•

Other food program

NAME

NAME OF PROGRAM

NAME

NAME OF PROGRAM

A. Does anyone live in any of the following:

•

Hospital or nursing home

■ YES ■ NO

CF Eligible Institution:

If "YES", complete below:

■ YES ■ NO

•

Shelter, center

•

Subsidized housing for the elderly

• Reservation for Native Americans

•

Drug or alcohol rehabilitation center

CA Eligible:

■ YES ■ NO

•

Psychiatric hospital/mental institution

•

Board and care home

•

Group living arrangement for the disabled/blind •

Penal institution/correctional facility

NAME

NAME OF CENTER, SHELTER, HOSPITAL, ETC.

DATE ENTERED

DATE EXPECTED TO LEAVE

Does the person who is in a hospital or nursing home have a spouse or

■ YES ■ NO

other family member at home?

List any child age 6-18 who does not attend school regularly and explain why he/she is not

School Attendence Verified:

attending regularly.

■ No Child Age 6-18

■ YES ■ NO

NAME

REASON NOT ATTENDING SCHOOL REGULARLY

Is anyone age 14 or older enrolled in school, college, or a

■ YES ■ NO School Enrollment Verif.:

training program? If "YES", complete below:

■ YES ■ NO

Date Verified:

NAME

AGE

NAME OF SCHOOL/COLLEGE/TRAINING

ENROLLED (✔) STATUS

UNITS/HOURS

WORKING

PROGRAM

■ Full time ■ Half time

PER WEEK

CF Eligible Student:

■ Other (specify):

■ YES

■ YES ■ NO

EXPECTED DATE

OF GRADUATION

■ NO

School Enrollment Verif.:

NAME

AGE

NAME OF SCHOOL/COLLEGE/TRAINING

ENROLLED (✔) STATUS

UNITS/HOURS

WORKING

■ YES ■ NO

PROGRAM

■ Full time ■ Half time

PER WEEK

Date Verified:

■ YES

■ Other (specify):

EXPECTED DATE

CF Eligible Student:

OF GRADUATION

■ NO

■ YES ■ NO

Complete below for anyone enrolled in college or attending a similar educational institution.

Expenses Verified:

NAME

TERM (✔) CHECK STATUS

TUITION/FEES PER TERM

BOOKS, EQUIPMENT, ETC., PER TERM

■ YES ■ NO

■ Semester ■ Year ■ Quarter

Date Verified:

MILES ROUND TRIP PER DAY TO

DAYS ATTENDING PER WEEK

TRANSPORTATION USED

SCHOOL/CHILD CARE

Financial Aid:

■ YES ■ NO

TRANSPORTATION COST PER WEEK

AMOUNT PAID PER WEEK BY CAR POOL MEMBERS

PUBLIC TRANSPORTATION (BUS, ETC.) PER DAY

■

MC 210 S-E

Is anyone under age 20 and pregnant or a parent?

■ YES ■ NO Referred to:

If "YES", complete below:

■

Cal-Learn

NAME

AGE

CHECK (✔) STATUS

■

CW 25

■ Pregnant

■ Teen Parent

■

CW 25A

SCHOOL STATUS, CHECK (✔)

■

Referred to Welfare-to-Work

■ Has a High School Diploma

■ Has a GED

■ Not Attending School Regularly (explain):

■ Currently Attending School Regularly

■ Other (explain):

Has anyone received a cash bonus or penalty, or help with child care,

■ YES ■ NO

transportation, etc. from the Cal-Learn Program?

If “YES”, complete below:

NAME

WHERE (COUNTY)

DATE(S) RECEIVED

19 Is anyone on strike?

■ YES ■ NO Striker Regs Apply:

If “YES”, complete below:

■ CA

■ CF

NAME OF STRIKER

NAME AND ADDRESS OF EMPLOYER/TRAINING PROGRAM

NAME OF UNION

DATE WENT ON STRIKE

MONTHLY INCOME (BEFORE DEDUCTIONS) EARNED FROM THIS JOB BEFORE THE

STRIKE

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

CA	20	Has anyone, including children, worked or does anyone expect to go to work,
CF		including part-time and occasional work? Check (✔) “YES” or “NO” for each item.	YES	NO
		If “YES”, complete below:	YES	NO
		Has anyone stopped or refused work or training within the last 60 days?

		Is anyone working or in training now?

Does anyone expect to be working or in training in the future? If “YES”, what is your anticipated start date?

If self-employed: For CalFresh: List your business expenses on a separate sheet of paper. For Cash Aid: Check (✔) how you want your business expenses figured each month:

■40% standard deduction ■ Actual business expenses ■ Monthly average (yearly business costs divided by 12 months). If actual, you must list your business expenses on a separate sheet of paper.

COUNTY USE ONLY

(A) (✔) if exempt			CF S/E Farmer
CA	MC	■ CF Adult	■ Yes ■ No
		■ CF Child
(B) (✔) if exempt			CF S/E Farmer
CA	MC	■ CF Adult	■ Yes ■ No

■CF Child

■Verif(s) on file for:

■ (A) ■ (B)

(A) NAME	NUMBER OF HOURS OF			EMPLOYER’S NAME AND ADDRESS
CA	WORK/TRAINING PER MONTH
	LAST MONTH__________
CF

MC	THIS MONTH__________
PAY DATE(S)	SELF-EMPLOYED		WAGES BEFORE DEDUCTIONS		DATE LAST CHECK RECEIVED
	■ YES	■ NO	$	per

REASON FOR LEAVING JOB/TRAINING					LAST DAY OF WORK/TRAINING

RECEIVED OR EXPECT TO RECEIVE TIPS OR COMMISSIONS

■YES ■ NO IF “YES”, COMPLETE BELOW: AMOUNT RECEIVED $ ________________

AMOUNT EXPECTED $ ________________

CF: Work history last 120 days
■ (A)	■ (B)
(A)		YES	NO
(A)		YES	NO
Empl. Statement
Good Cause Determ
Voluntary Quit

DATE NEXT CHECK EXPECTED

AMOUNT EXPECTED BEFORE

OCCUPATION

(A) ■ CA: 28 Days

(B) ■ CA: 28 Days

DEDUCTIONS

■ CF: 60 days

WILL THIS INCOME CONTINUE?

■ YES

■ NO

IF “NO”, EXPLAIN ANY KNOWN CHANGES HERE:

■ MC: 30 days

(B)

YES

(B) NAME

NUMBER OF HOURS OF

EMPLOYER NAME AND ADDRESS

Empl. Statement

WORK/TRAINING PER MONTH

LAST MONTH__________

Good Cause Determ

THIS MONTH__________

Voluntary Quit

PAY DATE(S)

SELF-EMPLOYED

WAGES BEFORE DEDUCTIONS

DATE LAST CHECK RECEIVED

RECEIVED OR EXPECT TO RECEIVE

CA: S/E Client Chooses:

■ YES

■ NO

TIPS OR COMMISSIONS

per

■ YES ■ NO IF “YES”, COMPLETE BELOW:

(A)

(B)

REASON FOR LEAVING JOB/TRAINING

LAST DAY OF WORK/TRAINING

AMOUNT RECEIVED

$ ________________

■ Actual

AMOUNT EXPECTED

$ ________________

■ 40% deduction

DATE NEXT CHECK EXPECTED

AMOUNT EXPECTED BEFORE

OCCUPATION

■ Annualize

DEDUCTIONS

WILL THIS INCOME CONTINUE?

■ YES

■ NO

IF “NO”, EXPLAIN ANY KNOWN CHANGES HERE:

21 A.

Does anyone pay for care of a child, disabled adult, or other dependent

■ YES ■ NO

Child Care Informing:

■ Trustline Informing (CCP 2)

so he/she can go to work, school, or look for a job?

If “YES”, complete below and ( ✔ ) if for work or training.

■ Health & Safety Certification

(CCP 5)

WHO GETS CARE

WHO PAYS

WHO GIVES CARE

■ WORK

AMOUNT PAID/HOW OFTEN

■ Dependent Care Verified

■ TRAINING

EVERY

WHO GETS CARE

WHO PAYS

WHO GIVES CARE

■ WORK

AMOUNT PAID/HOW OFTEN

DEP. CARE ELIGIBLE

YES

■ TRAINING

EVERY

Does anyone else pay all or part of your child care costs?

■ YES ■ NO

Is there another person in household

Include costs paid by a relative or friend not living in the home,

who could provide care?

Department of Education, Block Grant, etc. If “YES”, complete below:

■ YES ■ NO

NAME OF CHILD

WHO PAYS

MONTHLY AMOUNT PAID

WHO ELSE PAYS

MONTHLY AMOUNT PAID

NAME OF CHILD

WHO PAYS

MONTHLY AMOUNT PAID

WHO ELSE PAYS

MONTHLY AMOUNT PAID

If “YES”, who: __________________

Does anyone pay child or spousal support?

■ YES ■ NO

Court Order on File

■

YES

■

If “YES”, complete below:

Amount Ordered:

WHO PAYS

FOR WHOM

AMOUNT PER MONTH

Has anyone, including children, applied for or received unemployment or

■ YES ■ NO

disability insurance benefits in the last 12 months OR expect to receive these

benefits in the future?

If “YES”, complete below:

NAME

DATE APPLIED

WHERE (COUNTY/STATE)

DATE LAST RECEIVED

NAME

DATE APPLIED

WHERE (COUNTY/STATE)

DATE LAST RECEIVED

Has anyone received a Diversion cash payment or non-cash services from

■ YES ■ NO

any county or other state? If “YES”, complete below:

NAME

COUNTY/STATE

AMOUNT RECEIVED

LIST SERVICES RECEIVED

ESTIMATED VALUE

DATE RECEIVED

OF SERVICES

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 5 of 14

Employment HistoryPage 6 of 14

CA	25	Has any parent living in the home worked or been in training in the past 24 months?	■ YES ■ NO	COUNTY USE ONLY
CF		If "YES", complete below:

•Include all work done in and outside the United States (U.S.).

• Include work done in exchange for something besides money, such as rent, food, utilities or anything else.

PE/UIB Requirements

• Include any paid jobs the county helped you to get.

Earnings from month prior

• Begin with each person’s most recent job or training.

to month of application

A. NAME

IS HE/SHE A NATIVE AMERICAN?

■

YES

■

App Date: ____________

IF “YES”, LIST TRIBE:

Earnings from

________ to ________

Name and Address of Employer or

When Employed

Name and Address of Employer or

When Employed

Training Program

MO DAY YR

Amount

MO DAY YR

Amount

MO/YR

Training Program

From

Paid

From

Paid

( ✓ ) Check, If Work or Training

■

Work

■

Work

From

■

■ Weekly

■

■ Weekly

Training

■ Monthly

Training

■ Monthly

■

Work

■

Work

From

■

■ Weekly

■

■ Weekly

Training

■ Monthly

Training

■ Monthly

■

Work

■

Work

■

From

■ Weekly

■

From

■ Weekly

Training

■ Monthly

Training

■ Monthly

B. NAME

IS HE/SHE A NATIVE AMERICAN?

■

YES

■

IF ”YES”, LIST TRIBE:

Name and Address of Employer or

When Employed

Name and Address of Employer or

When Employed

Amount

Training Program

MO DAY YR

Amount

MO DAY YR

Training Program

From

Paid

( ✓ ) Check, If Work or Training

Paid

( ✓ ) Check, If Work or Training

■

Work

From

■

Work

From

■ Weekly

■

Training

■

Training

■ Monthly

■

Work

■

Work

From

■ Weekly

From

■ Weekly

■

Training

■

Training

■ Monthly

■

Work

■

Work

From

■

■ Weekly

■

■ Weekly

Training

■ Monthly

Training

■ Monthly

Are all CalFresh household members citizens of the United States (U.S.)?

■ YES ■ NO

If "NO", complete below for each CalFresh household member who is not a citizen of the U.S.

While living in the U.S., in how

A. How many years total has this

While living outside the U.S.,

Name of each

person, their spouse, and/or

many of the years reported in

how many total years did this

their parents (before this

Column A did this person, their

person, their spouse, and/or

noncitizen

person was 18 years old) lived

spouse, and/or their parents

their parents (before this

in the U.S.?

(before this person was 18

person was 18 years old) work

years old) earn money by

in the U.S?

working in the U.S.?

TOTAL

Tribal JOBS Referral

UIB Verif(s) on file

Must apply for UIB

Has anyone been in the U.S. military service or the spouse, parent, or child of a person who has

■ YES ■ NO

Currently

been in the military service? If "YES", complete below:

Receiving/Got/ or

UIB eligible in last

NAME

U.S. CITIZEN

(✔) STATUS

HONORABLE DISCHARGE

BRANCH OF SERVICE

DATE OF SERVICE

12 months

■ YES

■ ACTIVE DUTY MILITARY/VETERAN

■ YES

■ NO

UIB Ineligible Reason:

■ NO

■ SPOUSE, PARENT OR CHILD OF

ACTIVE DUTY MILITARY/VETERAN

NAME

U.S. CITIZEN

(✔) STATUS

HONORABLE DISCHARGE

BRANCH OF SERVICE

DATE OF SERVICE

■ YES

■ ACTIVE DUTY MILITARY/VETERAN

■ YES

■ NO

CF: ■ 40 Quarters Verif.

■ NO

■ SPOUSE, PARENT OR CHILD OF

ACTIVE DUTY MILITARY/VETERAN

COUNTY USE ONLY

■ CW 5

PRINCIPAL EARNER (PE) *

DATE OF APPLICATION

QUARTER OF APPLICATION

CF: Noncitizen’s Honorable

Discharge Verif.

*Principal Earner — the parent who earned the most income in the last 24 months prior to the month of application.

■ YES

■ NO

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

28 A. Does anyone, including children, get or expect to get money from any source listed below?

COUNTY USE ONLY

Check (✔) “YES” or “NO” for each item.

■ Casualty Unit Notified

Work Study, Welfare-to-Work,

YES

VA (Veterans) educational related

YES

■

CWC 6041

or other program

income

■ DHS 6155

Other training allowance

VA Aid & Attendence

■ Verif(s) on File

Explain Anticip. Income

Social Security disability or

Educational grants, loans

supplemental security income/state

Workers Comp:

and scholarships

supplementary payment (SSI/SSP)

■ Temporary ■ Permanent

CalWORKs/Cash aid from another state

VA disability

Refugee (RCA) Assistance

Railroad disability

Cash Assistance Program for Immigrants

Other disability income from a federal,

(CAPI)

state, or local governmental agency

GA/GR (General Assistance/Relief)

Other non-government disability or

sick leave

Workers Compensation

Social Security retirement or survivors

Child/spousal support or money for

Railroad retirement

medical bills or premiums

Other retirement income from a federal,

Strike benefits

state, or local governmental agency

Other non-government retirement

Loans, gifts, contributions

income

Legal or insurance settlements/

Per capita payments

court actions pending

Winnings (gambling/lottery/bingo,

Sales of notes, contracts, trust deeds,

prizes, etc.)

promissary notes

Other (Explain)

Military allotment or pension

If “YES”, complete below:

(✔) if exempt

NAME

SOURCE

(AMOUNT RECEIVED

WHEN

HOW OFTEN

BEFORE DEDUCTIONS)

B. Does anyone expect a change in the amount of money received now, such

■ YES ■ NO

as a cost-of-living raise?

If “YES”, complete below:

NAME

WHAT

AMOUNT

WHEN

Does anyone get housing or rent, utilities, food or clothing free or in

■ YES ■ NO

In-Kind Income:

29 exchange for work?

If “YES”, complete below and check (✔) if free or in exchange for work:

Verif. on file:

■ YES

■ NO

ITEM RECEIVED

Free

For Work

WHO RECEIVES THE ITEM

VALUE

WHO PROVIDES THE ITEM

Partial

Full

Earned

Unearned

Housing or rent

Utilities

Food

Clothing

30 A. Does anyone own or is anyone buying real estate, such as land

■ YES ■ NO

Home Exempt

■ YES ■ NO

and/or buildings anywhere, including outside the U.S.?

Other Real Property

If “YES”, complete below. Include land and/or buildings in which the title is shared.

Market Value

Amount Owed

TYPE (LAND, CONDO,

HOW DO YOU USE THIS

YES

OWNER(S)

ADDRESS OR LOCATION

AMOUNT

RENTAL

APARTMENT, HOUSE)

PROPERTY? CHECK (✔)

OWED

INCOME

Net Value

Lien Applicable

■ YES

■ NO

LIVE IN IT

Listed for sale

■ YES

■ NO

LISTED FOR SALE

RENTAL PROPERTY

■ YES ■ NO

Home Exempt

■ YES ■ NO

OTHER (EXPLAIN):

TYPE (LAND, CONDO,

HOW DO YOU USE THIS

YES

OWNER(S)

ADDRESS OR LOCATION

AMOUNT

RENTAL

Other Real Property

APARTMENT, HOUSE)

PROPERTY? CHECK (✔)

OWED

INCOME

Market Value

Amount Owed

LIVE IN IT

Net Value

LISTED FOR SALE

RENTAL PROPERTY

Lien Applicable

■ YES

■ NO

■ YES ■ NO

OTHER (EXPLAIN):

Listed for sale

■ YES

■ NO

B. Does anyone own a house that is not lived in now that he/she hopes

■ YES ■ NO

Total countable property: Page 7

to return to someday?

(List totals on page 9)

If “YES”, complete below:

OWNER OF PROPERTY

PROPERTY ADDRESS

EXPECTED DATE OF RETURN

(IF KNOWN)

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 7 of 14

Page 8 of 14

31 A. Does anyone, including children, have any of the following personal or business-related

COUNTY USE ONLY

resources? Check (✔) each item either “YES” or “NO”.

Include all resources owned, used, controlled, shared or held jointly with any person(s) (even for

convenience only). The county will determine whether or not these resources count.

■

Trust Fund/Not Court

Ordered

YES

■

Court Petitioned

Cash (on hand or elsewhere)

Trust funds (whether or not available)

Date ______________

Uncashed checks (on hand or elsewhere)

■

Resource Verified:

Notes, mortgages, deeds of trust, contracts

Explain how:

Savings accounts - children's and adult's

of sale, etc.

IRA or Keogh plans, etc.

Checking accounts - whether or not they are

Total Value = $________

used

Retirement funds which are available if you

Credit union accounts

stop work (such as PERS, etc.)

■ Burial Reserve or Trust (MCO)

Employee deferred compensation plans

Amount Owed $____________

Stocks, bonds, certificates of deposit, money

Life insurance or annuity

market accounts, etc.

■

Revocable

Oil, mining, or mineral rights

Life estate interest in any property

■

Irrevocable

Long term care insurance

Burial trusts or contracts, insurance,

■

Designated Fund

designated burial funds/money for cemetery

EBT cash balance from a previous month

and Current Value

plots, caskets, or other burial items

Other (explain)

$_____________

Income tax refund

■

CA Restricted Account

IF “YES”, COMPLETE BELOW:

RESOURCE

BUSINESS-

OWNER

ACCOUNT/POLICY NO.

NAME AND ADDRESS OF BANK, ETC.

CURRENT VALUE

Check (✔) if exempt

■ YES ■ NO

Does anyone get or expect to get money from any of the above

■ YES ■ NO

resources, such as interest, dividends, etc.?

If “YES”, complete below:

NAME

SOURCE OF MONEY

AMOUNT

HOW OFTEN

BUSINESS-RELATED

■ YES ■ NO

BUSINESS-RELATED

■ YES ■ NO

Are there any liens recorded or did you sign a security agreement with a

■ YES ■ NO

Verified:

■

YES

■

doctor, clinic, or hospital against any property owned by you or any family

member that is used as security for health care services?

If “YES”, complete below:

Lien Applicable:

■ YES ■ NO

LIEN OR SECURED

TYPE AND LOCATION OF PROPERTY

DATE AND TYPE OF MEDICAL CARE

NAME OF PROVIDER

Security Agreement: ■ YES ■ NO

AMOUNT

RECEIVED/TO BE RECEIVED

MC 174 completed

and sent:

■ YES ■ NO

A. Does anyone own any personal property, such as:

■ YES ■ NO

• Non-motorboats, camper shells, non-motor trailers.

• Guns; tools; or sporting equipment, etc.

■

Owned Jointly

• Pets or livestock for personal use.

• Jewelry, artwork, antiques, collections, cameras, musical equipment (pianos, guitars, amplifiers, etc.).

■

Owned Separately

If “YES”, complete below: Do not include wedding and engagement rings or heirlooms. List jewelry

worth more than $100 and household goods or personal items worth more than $500 per item.

■ Personal Property $500 + for

Pickle Program

ITEM

LISTED

PURCHASE PRICE

AMOUNT

ITEM

LISTED

PURCHASE PRICE

AMOUNT

■ Insignificant Value for 1931(b)

FOR SALE

OR CURRENT VALUE

OWED

FOR SALE

OR CURRENT VALUE

OWED

■ YES

■ Listed for sale

■ NO

(Specify):

■ YES

■ NO

B. Does anyone have any business property, including tools, inventory and

■ YES ■ NO

Total Countable Property: Page 8

materials, business equipment, livestock, etc.? Include any property that is

(List totals on Page 9)

shared or held jointly with any other person(s). If “YES”, complete below:

$ _____________________

ITEM

LISTED

PURCHASE PRICE

AMOUNT

ITEM

LISTED

PURCHASE PRICE

AMOUNT

FOR SALE

OR CURRENT VALUE

OWED

FOR SALE

OR CURRENT VALUE

OWED

$ _____________________

■ YES

$ _____________________

■ NO

■ Listed for sale

■ YES

(Specify):

■ NO

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Has anyone sold, spent, traded, transferred, or given away any real property,

■ YES ■ NO

COUNTY USE ONLY

such as a house or land; or personal property such as money, cars, bank

Transfer of Assets:

accounts, money from a legal or accident insurance settlement, or anything

■ CA in last 12 months

else? (List any property sold or traded within the last 12 months for cash aid,

3 months for CalFresh, and within the last 2 1/2 years (30 months) for Medi-Cal). If

■ CF in last 3 months

“YES”, explain what and when:

■ Medi-Cal in last 30 months

LTC ONLY

■ Adequate Consideration

■ Spenddown

35 Does anyone own, have the use of or have their name on the registration of any

■ YES ■ NO

Total Nonexempt Property

motor vehicle, such as: automobile, motorcycle, snowmobile, recreational

vehicle, motorboat, etc., even if not running? If “YES”, complete below. Look at

your registration to get facts for each vehicle:

Compute Vehicle Valuation in

VEHICLE (1)

VEHICLE (2)

VEHICLE (3)

Section Below:

OWNER OF VEHICLE

■

Verifications viewed

■

Leased vehicle:

NAME OF PERSON

WHO USES VEHICLE

■ (1)

■ (2) ■ (3)

YEAR/MAKE/MODEL

■

Pickle Program:

Use Pickle Handbook

LICENSE NUMBER

(Reference Section 9)

ESTIMATED VALUE

BALANCE OWED

LICENSED

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

LEASED

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

HOW DO YOU USE THE

VEHICLE? Check (✔) each

item “YES” OR “NO.”

YES

Vehicle Value

As a Home

(Enter Date of blue book issue or other

documentation)

To go to work or training or

for job search

For self-employment, self-

(1) Date: ___________$ ___________

support, or business use

Needed for disabled

(2) Date: ___________$ ___________

household member

To get household’s fuel or

(3) Date: ___________$ ___________

water

For recreational use only

COUNTY USE ONLY - VEHICLES

CASH AID

VEHICLE (1)

VEHICLE (2)

VEHICLE (3)

FMV

(A) Is vehicle a home, income

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

Minus

producing, primary transportation to

$4,650

get fuel/water, or used for a disabled

(Exclude)

Go to (B).

(Exclude)

Go to (B).

(Exclude)

Go to (B).

Excess

household member? (63-501.521)

Value

(B) (1) Equity: exempt one vehicle,

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

(D)

Equity Values-CA

regardless of use. (63-501.523) [If

FMV

“YES”, go to (C). If “NO”, go to (B)(2).]

(2) Is other vehicle(s) used for job

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

Minus

Encum-

search, employment or training?

Go to (C) and

Go to (C).

brance

Use Excess

(D). Use

Use Excess

(D). Use

Use Excess (D). Use

Equity

Value.

Greater Value.

Value.

Greater Value.

Value.

Greater Value.

Value

MEDI-CAL

TOTALS: VEHICLE

(1)

(2)

(3)

Excess Value

$ ________________

DMV/YR/Class Code

__________

Equity Value

$ ________________

Vehicle Market Value

$ _________

Less Encumbrances

$ _________

Grand Total Countable Property

Net Value

$ _________

(List totals from pages 7, 8, and 9)

Exempt

■ Y ■ N

■ Y

■ N

■ Y ■ N

Page

(9)

$___________ $___________ $___________

Pickle Program (Ref. Sec. 9 in Pickle Handbook):

(1)

(2)

(3)

Is vehicle used:

Exempt

Yes

(8)

$___________ $___________ $___________

As a home

(7)

$___________ $___________ $___________

For self-employment

Total

$___________ $___________ $___________

To Go to Work or Medical Appointment

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 9 of 14

Page 10 of 14

A. Does anyone have any housing costs?

■ YES ■ NO

COUNTY USE ONLY

If “YES”, complete below:

Housing verified:

■ YES ■ NO

HOUSING

TOTAL

HOW MUCH

HOW MUCH OTHER FAMILY/

HOW OFTEN

COSTS

COST

YOU PAY

HOUSEHOLD MEMBERS PAY

BILLED

Total housing: $ ___________

Rent

Shared housing:

■ YES ■ NO

House (mortgage) payment

Property taxes (if not in house

payment)

Insurance (if not in house payment)

Other (explain)

B. Does anyone else pay all or part of these housing costs? Include a

■ YES ■ NO

relative or friend not living in the home, any rental assistance programs,

such as HUD, Section 8, etc. If “YES”, complete below:

TYPE OF HOUSING COST

NAME OF PERSON WHO PAYS

HOW MUCH EACH PAYS

HOW OFTEN BILLED

A. Does anyone have any utility costs?

■ YES ■ NO

If “YES”, please check all boxes below that apply.

Gas

Garbage or trash

Utilities verified:

■ YES

■ NO

Electricity

Sewer

Verification not required

■

Other fuel (such as propane,

Telephone/other means of

butane, wood, coal, etc)

communication, such as internet, etc.

Water

Other (explain)

Utility allowance

B. Do you use gas, electricity or other fuel for heating or cooling?

■ YES ■ NO

■ SUA

If ‘YES”, please check below.

■ LUA

■ TUA

UTILITY

USED FOR HEATING OR COOLING?

■ None allowed

Gas

■ YES

■ NO

Electricity

■ YES

■ NO

Other Fuel

■ YES

■ NO

CF 38	You can authorize someone else in your household or someone outside your household to use			■ CalFresh I.D. Issued
CF 38	your CalFresh benefits to buy food for you. If you would like to authorize someone, complete			■ CalFresh I.D. Issued

	below:

NAME OF AUTHORIZED REPRESENTATIVE		ADDRESS	PHONE

( )

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Did anyone get medical/pregnancy treatment this month or in the

■ YES ■ NO

COUNTY USE ONLY

three months before this month?

Retroactive Application

If “YES”, complete below:

NAME OF PERSON RECEIVING CARE

MONTHS OF CARE

PAYMENTS MADE

DO YOU WANT MEDI-CAL

■

Retro Only

FOR CARE

FOR THOSE MONTHS?

YES

■

Retro and Cont.

■

MC 210A

Does anyone have MEDICARE coverage?

■ YES ■ NO

■

If “YES”, complete below:

MEDICARE referral

(✔) HOW MONTHLY PREMIUM IS PAID

CF: ■ DFA 285-C

PERSON COVERED

MEDICARE CLAIM NUMBER

FOR

DEDUCTED FROM

OUT OF POCKET

OTHER

Gross Premium $ ________

CHECK

■

Part A

QMB

■

SLMB/QI

Part B

■

QDWI

Part A

Part B

Does anyone have health, dental, vision, hospitalization or Long Term Care

■ YES ■ NO

State Certified LTC Policy:

insurance or health plans, such as Kaiser, Blue Cross, CHAMPUS, etc.?

■ YES ■ NO

If “YES”, complete below:

■ DHS 6155

INSURANCE COMPANY

PERSON INSURED

EXPIRATION DATE

PREMIUM

AMOUNT

HOW OFTEN PAID

Benefits Paid Out $_____________

Does anyone have any health insurance available from a parent, employer,

■ YES ■ NO

or absent parent, which has not been applied for?

If “YES”, complete below:

INSURANCE COMPANY

PERSON TO BE INSURED

PREMIUM

AMOUNT

HOW OFTEN PAID

■

DHS 6155

Is anyone’s health insurance expected to end or has it ended within the

■ YES ■ NO

■

DHS 6155

last 60 days?

If “YES”, complete below:

INSURANCE COMPANY

PERSON INSURED

EXPIRATION DATE

PREMIUM

AMOUNT

HOW OFTEN PAID

Does anyone have a disability caused by injury or accident which makes it

■ YES ■ NO

difficult for them to work or take care of their needs?

■

Third Party Liability

If “YES”, complete below:

NAME OF PERSON

TYPE OF PROBLEM

DATE PROBLEM

EXPECTED DATE

STARTED

OF RECOVERY

A. Does anyone have a medical condition(s) or situation(s) that requires any of the following?

Check (✔) each item “YES” or “NO”:

YES

Verified:

■ YES ■ NO

Special diet—prescribed by a doctor

Very high use of utilities

Special Need:

■ YES ■ NO

Special transportation need

Special laundry service

Amount:

$ _______________

Special telephone or other equipment

Other (specify):

Housework (no one in the home can do it)

If “YES”, explain:

B. Is there a child or disabled person in the household who needs care from

■ YES ■ NO

another household member?

If “YES”, explain:

C. Is anyone a disabled person who is working and who has medical expenses

■ YES ■ NO

■

Receipts

(wheelchair, etc.), which are needed for the person to be able to work?

■

MC 272

■ MC 273

If “YES”, complete below:

NAME OF PERSON

TYPE OF EXPENSE

AMOUNT

■ IRWE (QMB and SGA)

CF: ■ DFA 285-C

D. Is anyone getting In-Home Supportive Services (IHSS)?

■ YES ■ NO

If “YES”, who gets service? _____________ How much do you pay each month? $__________

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 11 of 14

							Page 12 of 14

CA	46	Does the household want to apply for a special need payment for housing	■ YES ■ NO			COUNTY USE ONLY
		or essential household items lost or damaged due to sudden and unusual						YES	NO
		circumstances, such as an earthquake, fire, or flood?			Special Need Verified
		If “YES”, explain below.
		If “YES”, explain below.			Eligible for Special Need
					Eligible for Special Need


CA	47	Are you or any member of the household hiding or running from the law to	■ YES ■ NO
CF	47	avoid prosecution, being taken into custody, or going to jail for a felony
		crime or attempted felony crime? If “YES”, give name of the person:

CA	48	Have you or any member of your household been found by a court of law to	■ YES ■ NO
CF	48	be in violation of probation or parole? If “YES”, give name of the person:

CA	49	Have you or any member of your household been convicted of a drug-related	■ YES ■ NO		CF convictions after 8/22/96
CF		felony? If No, go to question 50.			CW convictions after 1/1/98
					CW convictions after 1/1/98
		If Yes, Name: __________________________ Date convicted: ______________ .
		Was the conviction for any of the following:
		● Transporting, importing into this state, selling, furnishing, administering, giving
		away, possessing for sale, purchasing for the purposes of sale, manufacturing,			Qualifying Drug Felon?
		or processing precursors with the intent to manufacture a controlled substance	■ YES ■ NO		■ Yes		■ No
		or cultivating, harvesting, or processing marijuana?	■ YES ■ NO		■ Yes		■ No
		● Encouraging, inducing, soliciting or intimidating a minor to participate in any of	■ YES ■ NO		Meets felony conditions of
			■ YES ■ NO		eligibility?
		the above activities?			eligibility?
		Have you or any member of your household:			■ Yes		■ No
		Have you or any member of your household:
		a) Completed a government recognized drug treatment program?	■ YES ■ NO
		b) Participated in a government recognized drug treatment program?	■ YES ■ NO
		c) Enrolled in a government recognized drug treatment program?	■ YES ■ NO

		d) Been placed on a waiting list for a government recognized drug treatment	■ YES ■ NO
		program?
		e) Stopped the use of controlled substances and have evidence that you have	■ YES ■ NO
		stopped?	■ YES ■ NO
		If Yes, please explain: ________________________________________________

CA	50	The following services are available. Your answers to these questions will not		YES NO	■	CHDP Brochure and
MC	50			YES NO		CHDP Brochure and
		affect your eligibility. Check (✔) each item “YES” or “NO.”				Explanation Given
		A. Regular check-ups to help protect your family’s health are available upon request				Date: ___________________

		through the Child Health and Disability Prevention Program (CHDP) for eligible			■	CHDP Referral
		members of your family under age 21.			■	CHDP Referral
		members of your family under age 21.
		• Do you want more information about CHDP Services?			■	Social Services Referral
		• Do you want CHDP medical services?			■	Social Services Referral
		• Do you want CHDP medical services?				(MCO)
						(MCO)

•Do you want CHDP dental services? ..........................................................

•Do you need help making appointments or with transportation

to CHDP services? .........................................................................................................

B.	Do you want more information about immunization services?	■ Referred for Immuniz.
		■ Referred for Immuniz.

C.	If you are pregnant, you can get help finding a doctor, getting healthy foods, and	■ Pregnant	■ Parent or
	other help. Do you want to talk to someone about this help?		Guardian of
	other help. Do you want to talk to someone about this help?		child under 5
			child under 5
D.	Are you breastfeeding a child?	■ Breastfeeding	■ Postpartum
	If “YES”, have you given birth within the last 12 months?
	If you checked “YES” to 50 C or D, you may be eligible for services provided by	■ WIC referral
	the Special Supplemental Food Program for Women, Infants and Children (WIC).

E.	Do you or any family member want free or low-cost family planning services to	■ Family Planning
	help plan how to prevent unplanned pregnancies and/or have the next child? If	Information Given
		■ Referred Date:
	“YES”, call your health care plan or regular doctor. Or, for facts and the location	■ Referred Date:

	of confidential family planning clinics, call toll-free 1-800-942-1054.

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

CERTIFICATION

I understand that:

•Any facts I gave, including benefit and income facts, will be matched with local, state and federal records, such as employers, the Social Security Administration, tax, welfare and unemployment agencies, school attendance, etc. And for cash aid and CalFresh, records will be matched with law enforcement agencies for arrest warrants.

•All facts, including benefit and income facts, I gave may be reviewed and checked out by county, state, and federal personnel, and that if I gave wrong facts, my cash aid, CalFresh, and Medi-Cal may be denied or stopped.

•My case may be picked for reviews to ensure that my eligibility was correctly figured and that I must cooperate fully with county, state or federal personnel in any investigation or review, including a quality control review.

•The county will send facts to the U.S. Citizenship and Immigration Services (USCIS) (Formerly INS) to verify immigration status and the facts the county gets from USCIS may affect my eligibility for cash aid, CalFresh, and full Medi-Cal. But if I am applying for Medi-Cal Only, AND if I am not (a) a lawful permanent resident noncitizen (LPR), (b) an amnesty alien with a valid and current I-688, or (c) a noncitizen permanently residing in the United States under color of law (PRUCOL), the county will not send facts to the USCIS.

•I must apply for and keep any available health coverage if no cost is involved; if I do not my Medi-Cal will be denied or stopped.

•I or other family members will be required to repay any cash aid I should not have received.

•The CalFresh household, any adult member of a CalFresh household (even if he/she moves out), the sponsor of a noncitizen household member or the authorized representative of residents in an eligible institution may be required to repay any benefits the household should not have received.

•Any member of my household who is hiding or running from the law to avoid prosecution, being taken into custody, or going to jail for a felony crime or attempted felony crime or has been found by a court of law to be in violation of their probation or parole cannot get cash aid or CalFresh.

•Any household member who has been convicted after August 22, 1996 of a drug-related felony for possession, use, manufacturing, sale, distribution of a controlled substance, or any activity in connection with these unlawful acts, or harvesting, cultivating or processing marijuana, or involving a minor in the above activities, cannot receive CalFresh.

•For cash aid, the county will require that I and certain household members be fingerprint and photo imaged. My benefits may be denied or stopped if I do not cooperate.

I also understand that:

I will get disqualification and/or welfare fraud penalties if on purpose I give wrong facts or fail to report all facts or situations that affect my eligibility or benefits for cash aid, CalFresh, and Medi- Cal.

For cash aid:

•If I on purpose do not follow cash aid rules, I may be fined up to $10,000 and/or sent to jail/prison for 3 years. And my cash aid can be stopped:

-For not reporting all facts or for giving wrong facts: 6 months for the first offense, 12 months for the second, or forever for the third; and for Refugee Cash Assistance, 3 months for the first and 6 months for any later offense.

-For submitting one or more applications to get aid in more than one case at the same time: 2 years for the first conviction, 4 years for the second, or forever for the third.

-For conviction of felony thefts to get aid: 2 years for theft of amounts under $2000; 5 years for amounts of $2000 through $4999.99; and forever for amounts of $5000 or more.

-For giving the county false proof of residency in order to get aid in two or more counties or states at the same time; giving the county false proof for an ineligible child or a child that does not exist; getting more than $10,000 in cash benefits through fraud; getting a third conviction for fraud in a court of law or an administrative hearing: forever.

For CalFresh:

•If on purpose I do not follow CalFresh rules, my CalFresh will be stopped for 12 months for the first violation, 24 months for the second, and forever for the third. And I may be fined up to $250,000 and/or sent to jail/prison for 20 years.

•If I am found guilty in any court of law because:

-I traded or sold CalFresh benefits for firearms, ammunition, or explosives, my CalFresh benefits can be stopped forever for the first violation.

-I traded or sold CalFresh benefits for controlled substances, my CalFresh benefits can be stopped for 24 months for the first violation and forever for the second.

-I traded or sold CalFresh benefits that were worth $500 or more, my CalFresh benefits can be stopped forever.

-I filed two or more applications for CalFresh benefits at the same time and gave the county false identity or residence information, my CalFresh benefits can be stopped for 10 years.

I declare under penalty of perjury under the laws of the United States of America and the State of California that the information in this statement of facts is true, correct, and complete.

SIGNATURE (PARENT OR CARETAKER RELATIVE, MEDI-CAL APPLICANT, ADULT CALFRESH HOUSEHOLD MEMBER OR CALFRESH AUTHORIZED REPRESENTATIVE)			DATE

SIGNATURE (SPOUSE, REGISTERED DOMESTIC PARTNER, OR OTHER PARENT	DATE	SIGNATURE OF WITNESS TO MARK, INTERPRETER OR PERSON	DATE
LIVING IN THE HOME, IF APPLYING FOR CASH AID)		ACTING FOR APPLICANT/BENEFICIARY

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Page 13 of 14

Page 14 of 14

COUNTY USE ONLY

ELIGIBILITY FACTORS REVIEWED

CA	CF	MC	CA	CF	MC
YES NO YES NO YES NO			YES NO YES NO YES NO
Residency			Property/Resources—Within
Deprivation			limits
Age			Work participation
Immunizations			Employment & Training
Immunizations			(E & T)
Citizen/Eligible			(E & T)
Citizen/Eligible			ABAWDs
noncitizen			ABAWDs
noncitizen
School enrollment			CFAP
Pregnancy verif./			Sponsored noncitizen
			Sponsored noncitizen
WIC Referral			Federal participation
SSN			established (If “NO”, explain)
Income—			Referred for Health Care
Applicant/Recipient			Options (HCO) Presentation
test(s)			Options (HCO) Presentation
test(s)
SFIS
TANF Time Limits
CALWORKS TIME LIMITS

CalFresh TESTS

YES NO NA

Categorically Eligible

Gross Income Test

Household Size

Gross Monthly Income $

Gross Income Eligible

Separate HH Income Test

Household Size

Gross Monthly Income $

Eligible for Separate

HHStatus Aged/Disabled DFA 285-C

Gross Income less than $150 and cash on hand, checking and savings accounts of $100 or less?

Combined gross income and liquid resources less than the combined rent/mortgage and appropriate utility allowance?

Migrant/seasonal farm worker household with liquid resources not exceeding $100?

COMMENTS

AU Size:		Non-AU Size:	AU/MFBU Size:

■ INELIGIBLE (REASON)

■ ELIGIBLE	■ DIVERSION			AUTHORIZATION DATE
■ ELIGIBLE	■ DIVERSION
■ REDETERMINATION	■ EXEMPT MAP

ELIGIBILITY CONDITIONS MET (DATE):				EFFECTIVE DATE

WORKER‘S SIGNATURE				DATE

SUPERVISOR‘S SIGNATURE (COUNTY OPTION)				DATE

CF:

HH Size:

■INELIGIBLE (REASON)

■ ELIGIBLE	AUTHORIZATION DATE

■RECERTIFICATION


	WORKER‘S SIGNATURE	DATE

	SUPERVISOR‘S SIGNATURE (COUNTY OPTION)	DATE

SAWS 2 (4/13) SAWS 2/DFA 285-A2/MC 210 REQUIRED FORM - SUBSTITUTE PERMITTED

Question	Answer
Form Name	Statment Of Fact For Food Stamps Form
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	medi, SSN, NONCITIZEN, california

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

Statment Of Fact For Food Stamps Form PDF Details

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

Statment Of Fact For Food Stamps Form PDF Details

Form Preview Example

Statment Of Fact For Food Stamps Form isn’t the one you’re looking for?

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