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APPLICATION FOR CALFRESH , CASH AID , AND/OR (California)

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APPLICATION FOR CALFRESH , CASH AID , AND/OR
MEDI-CAL/HEALTH CARE PROGRAMS
If you have a disability or need help with this application, let the County Welfare Department (County) know and
someone will help you.
If you prefer to speak, read, or write in a language other than English, the County will get someone to help you
at no cost to you.
How do I apply?
Use this application if you are applying for food assistance (CalFresh), cash aid (California Work Opportunity and
Responsibility to Kids, Refugee Cash Assistance, General Assistance or General Relief), Medi-Cal and/or other
health care programs. If you want to apply for CalFresh only, you can ask the County for the CalFresh only
application. CalFresh is a food assistance program to help you with the cost of buying food for your household.
If you want to apply for health care only, you can ask the county for a health care only application. Health care
includes: low-cost insurance for Medi-Cal; affordable private health insurance; or a tax credit that can help you
pay your premiums for health coverage. Do not use this application if you are applying for only health care. Your
County may have a separate application for General Assistance or General Relief. Ask your County to be sure.
You can also apply for these programs online by going to http://www.benefitscal.org/.
• Fill out the whole application form, if you can. You must at least give the County your name, address, and
signature (question 1 on page 1 of the application) to begin the application process for CalFresh. For cash aid
you must fill out questions 1 through 5 on pages 1 and 2 of the application and sign it to begin the application
process. For General Assistance or General Relief ask the County which questions must be answered to begin
the application process.
• Each program has a symbol (shown at the top of this page) showing what questions pertain to what programs.
For cash aid, it is a dollar sign; for CalFresh, it is a shopping cart; and for health coverage, it is an ambulance.
For example, if you are not applying for cash aid, you don’t need to answer questions marked only with a dollar
sign.
• Give the application to the County in person, by mail, by fax or online.
• The day the County receives your signed application starts the time to give you an answer on whether you can
get benefits. If you are in an institution, this time starts from the day you leave.
What do I do next?
• Read about your rights and your responsibilities (Program Rules pages) before you sign the application.
• You must have an interview with the County to discuss your application. If you have a disability, other
arrangements can be made.
• If you did not fill out all of the application, you can finish it during your interview.
• You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.
How long will it take?
It may take up to 30 days to process your application for CalFresh. For cash aid and Medi-Cal, it may take up to
45 days. Ask the County how to get your benefits or health care right away if you have an emergency.
You may be able to get CalFresh benefits within 3 calendar days if
:
• Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand
or in checking or savings accounts is not more than $100; or
• Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
money in checking or savings; or
• You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your
income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.
For cash aid, you may get immediate assistance if
:
• You are homeless or have an eviction notice or a notice to pay rent or move; or
• Your food will run out within three days; or
• Your utilities have been or will be shut off; or
• You don’t have sufficient clothing or diapers; or
• You have another kind of emergency important to health and safety.
Informational Page - Please take and keep for your records.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SAWS 2 PLUS (4/15)
COVERSHEET PAGE 1 OF 2
To help the County see if you can get benefits faster, please complete questions 1, 6 through 9, 15, and 24, and
give the County proof of your identity (if you have it) with the application. For General Assistance or General
Relief, ask the County how long it will take and about any special rules for getting benefits faster.
The County will send you a letter to let you know if your household is approved or denied for the benefits you
applied for.
What do I need for my interview?
To avoid delays, bring proof of the following items with you to your interview. Keep your interview even if you do
not have the proof. The County may be able to help if you need help getting proof. During the interview, the
County will go over the information on the application and will ask you questions to see if you can get benefits
and the amount of benefits you can get.
Proof Needed to Get More
CalFresh Benefits
• Housing costs (rent receipts, mortgage bills,
property tax bill, insurance documents).
• Phone and utility costs.
• Medical expenses for anyone in your household
who is elderly (60 and older) or disabled.
• Child and adult care costs due to someone
working, looking for work, attending training or
school, or participating in a required work activity.
• Child support paid by a person in your
household.
Additional Proof Needed for Health Coverage
• Information about any job related health
insurance available to your family.
• Policy numbers for any current health insurance.
Additional Proof Needed for Cash Aid
• Proof of immunizations for children six years of
age or younger.
• Vehicle registration for vehicles owned by you or
someone you are applying for.
Proof Needed to Get Benefits
• Identification (Driver’s License, State ID card,
passport).
• Birth certificates for everyone applying for cash
aid.
• Proof of where you live (rental agreement, cur-
rent bill with your address listed).
• Social Security numbers for everyone applying
for aid (see note below about certain
noncitizens).
• Money in the bank for all the people in your
household (recent bank statements).
• Earned income of everyone in your household
for the past 30 days (recent pay stubs, a work
statement from an employer). NOTE: If
self-employed, income and expenses or tax
records.
• Unearned income (Unemployment benefits, SSI,
Social Security, Veteran’s benefits, child support,
worker’s compensation, school grants or loans,
rental income, etc.).
• Lawful immigration status ONLY for legal
noncitizens applying for benefits (an Alien
Registration Card, visa).
NOTE: Certain noncitizens applying for
immigration status based on domestic violence,
crime prosecution or trafficking may not need this
proof. They also may not need a Social Security
Number.
What if I am homeless?
Please let the County know right away if you are homeless so they can help you figure out an address to use to
accept your application and get notices from the County regarding your case. For CalFresh and cash aid,
homeless means you are:
A. Staying in a supervised shelter, halfway house, or similar place.
B. Staying at the home of another person or family for no more than 90 days straight.
C. Sleeping in a place not designed for, or normally used as, a place to sleep (a hallway, a bus station, a
lobby, or similar places).
SAWS 2 PLUS (4/15)
Informational Page - Please take and keep for your records.
COVERSHEET PAGE 2 OF 2
SAWS 2 PLUS (4/15)
PROGRAM RULES PAGE 1 OF 4
RIGHTS AND RESPONSIBILITIES
You have a responsibility to:
• Give the County all information needed to determine your eligibility.
• Give the County proof of the information you have when it is needed.
• Report changes as required. The County will give you information about what, when, and how to report. For CalFresh
and cash aid if you don’t meet your household’s reporting requirements, your case may be closed or your benefits may
be lowered or stopped.
• Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your case.
• Fully cooperate with county, state, or federal personnel if your case is selected for review or investigation to ensure that
your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will result in loss of your
benefits.
• Pay back any cash aid or CalFresh benefits that you were not eligible to get.
You have the right to:
• Turn in an application for CalFresh giving only your name, address, and signature.
• Have an interpreter provided by the State at no cost if you need one.
• Have information given to the County kept confidential, unless directly related to the administration of County programs.
• Withdraw your application at any time prior to the County determining eligibility.
• Ask for help to fill out your application or help getting the proof that you need and get an explanation of the rules.
• Be treated with courtesy, consideration, and respect, and not be discriminated against.
• Get CalFresh benefits within 3 days if you qualify for Expedited Service.
• Get cash aid within one day if you qualify for Immediate Need.
• Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility determined
within 30 days for CalFresh or 45 days for cash aid and Medi-Cal.
• Get at least 10 days to give to the County proof that is needed to make a determination of eligibility.
• Get written notice at least 10 days before the County lowers or stops your CalFresh or cash aid benefits.
• Discuss your case with the County and to review your case when you ask to do so.
• Ask for a State hearing within 90 days if you do not agree with the County about your case. If you ask for a hearing
before an action on your case takes place, your benefits will stay the same until the hearing or the end of your certification
period, whichever is earlier. You can ask the County to let your benefits change until after the hearing to avoid having to
pay back any overpaid benefits. If the Administrative Law Judge rules in your favor, the County will give back to you any
benefits that were cut.
• Ask about your hearing rights or for a legal aid referral at the toll-free phone numbers – 1-800-952-5253 or for hearing
or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal aid or welfare rights
office.
• Bring a friend or someone with you to the hearing if you do not want to go alone.
• Get help from the County to register to vote.
• Report changes that you are not required to report, if it may increase your CalFresh benefits or cash aid.
• Give proof of your household’s expenses that may help you get more CalFresh benefits. Not giving proof to the County
is the same as saying that you do not have that expense and you will not be able to get more CalFresh benefits.
• Let the County know if you would like someone else to use your CalFresh benefits for your household or help with your
CalFresh case (Authorized Representative).
You are also giving the Medi-Cal agency the right to pursue and get medical support from a spouse or parent. If you
think that cooperating to collect medical support will harm you or your children, you can tell the Medi-Cal agency and
you may not have to cooperate.
Please take and keep for your records
SAWS 2 PLUS (4/15)
PROGRAM RULES PAGE 2 OF 4
Program Rules and Penalties
You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get
CalFresh, cash aid, and Medi-Cal, that you are not eligible to receive, or to help someone else get benefits that they are not
eligible to receive. You must pay back any benefits you get that you were not eligible to receive. If you do this on purpose
and receive more than $950 in benefits you were not eligible to receive, you can be charged with a felony.
For CalFresh: I understand that if I commit an
intentional program violation by doing any of the
following:
• hide information or make false statements
• use electronic benefit transfer (EBT) cards that belong
to someone else or let someone else use my card
• use CalFresh benefits to buy alcohol or tobacco
• trade, sell, or give away CalFresh benefits or EBT cards
• trade CalFresh benefits for controlled substances,
such as drugs
• give false information about who I am and where I live
so I can get extra CalFresh benefits
• have been convicted of trading or selling CalFresh
benefits worth more than $500, or trading CalFresh
benefits for firearms, ammunition, or explosives
For cash aid I understand that if I...
• am convicted of an intentional program violation
• do not follow cash aid rules
• am found guilty by a court of law or an administrative
hearing of committing certain types of fraud
Important Information for Noncitizens
• You can apply for and get CalFresh benefits, cash aid, or health care for people who are eligible, even if your family in-
cludes others who are not eligible. For example, immigrant parents may apply for CalFresh benefits, cash aid, or health
care for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible.
• Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and
confidential.
• The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S. Citizenship
and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except
cases of fraud.
Opting Out
You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s)
who are not applying for benefits. The County will need to know their income and resource information to correctly determine
your household’s benefits. The County will not contact USCIS about the people who don’t apply for benefits.
Use of Social Security Numbers (SSN)
CalFresh and Cash Aid: Everyone applying for CalFresh benefits or cash aid needs to provide a SSN, if you have one, or
proof that you have applied for a SSN (such as a letter from the Social Security office). We can deny you or any member of
your household who does not give us a SSN. Some people do not have to give SSNs to get help such as, victims of domestic
abuse, crime prosecution witnesses, and trafficking victims.
Health Coverage/Medi-Cal: We need your SSN if you want health coverage and have a SSN. Providing your SSN can be
helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income
and other information to see who’s eligible for help with health coverage costs. If someone wants help getting a SSN,
Call 1-800-772-1213 or visit the website: www.socialsecurity.gov
Overissuance
This means you got more CalFresh benefits than you should have. You will have to pay it back even if the county made an
error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of
benefits owed, through the courts, other collection agencies, or federal government collection action.
Please take and keep for your records
I may...
• lose CalFresh benefits for 12 months for the first offense
and be required to repay all CalFresh benefits overpaid
to me
• lose CalFresh benefits for 24 months for the second
offense and be required to repay all CalFresh benefits
overpaid to me
• lose CalFresh benefits permanently for the third offense
and be required to repay all CalFresh benefits overpaid
to me
• be fined up to $250,000, imprisoned up to 20 years, or
both
• lose CalFresh benefits for 24 months for the first offense
• lose CalFresh benefits permanently for the second
offense.
• lose CalFresh benefits for 10 years for each offense
• lose CalFresh benefits forever
I may...
• lose my cash aid
• be fined up to $10,000 and/or sent to jail/prison for
5 years
• lose cash aid for 6 months, 12 months, 2 years, 4 years,
5 years, or forever.
SAWS 2 PLUS (4/15)
PROGRAM RULES PAGE 3 OF 4
Overpayment
This means that you got more cash aid than you should have gotten. Just like with CalFresh benefits, you will have to pay
it back even if the County made an error or if it wasn’t on purpose. Your cash aid may be lowered or stopped. Your SSN may
be used to collect the amount of benefits owed, through the courts, other collection agencies, or federal government collection
action.
Reporting
Every household that gets benefits must report certain changes. Your county will tell you what changes to report, how to
report them, and when to report them. Failure to report the changes may result in your benefits being lowered or stopped.
You can also report if things happen that may increase your benefits, such as getting less income.
State Hearings
You have the right to a State hearing if you do not agree with any action taken regarding your application or your ongoing
benefits. You can request a State hearing within 90 days of the County’s action and you must tell why you want a hearing.
The approval or denial notice you receive from the County will have information on how to request an appeal. If you ask for
a hearing before the action happens, you may be able to keep your cash aid and CalFresh benefits the same until a decision
is made.
Privacy Act and Disclosure
You are giving personal information in the application. The County uses the information to see if you are eligible for benefits.
If you do not give the information, the County may deny your application. You have a right to review, change, or correct any
information that you gave to the County. The County will not show your information or give it to others unless you give them
permission or federal and state law allows them to do so. The County will verify this information through computer matching
programs, including the Income and Earnings Verification System (IEVS). This information will be used to monitor compliance
with program regulations and for program management. The County may share this information with other federal and state
agencies for official examination, with law enforcement officials for the purpose of arresting persons fleeing to avoid the law,
and with private claims collection agencies for claims collection action. The County may verify immigration status of household
members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your
eligibility and level of benefits.
The County will use the information from your application to check your eligibility for help with paying for health coverage.
The County will check your answers using information in state and federal electronic databases and databases from the
Internal Revenue Service (IRS), Social Security Administration, the Department of Homeland Security, and/or a consumer
reporting agency. If the information doesn’t match, the County may ask you to send proof.
Nondiscrimination
It is the State and County’s policy that all people be treated equally, and with respect and dignity. In accordance with federal
law and the U.S. Department of Agriculture (USDA) Policy, discriminating on the basis of race, color, national origin, sex,
age, religion, political beliefs, or disabilities is strictly prohibited.
To file a complaint of discrimination, either contact your County’s Civil Rights Coordinator, or write to or call the USDA or
California Department of Social Services (CDSS):
USDA, Director
Office of Civil Rights, Room 326-W
Whitten Building
1400 Independence Ave.
Washington D.C. 20250-9410
1-202-720-5964 (voice and TDD)
USDA is an equal opportunity employer.
Work Rules for CalFresh
The county may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you
have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.
You may not be eligible for CalFresh if you have recently quit a job.
Please take and keep for your records
CDSS
Civil Rights Bureau
P.O. BOX 944243, M.S. 8-16-70
Sacramento, CA 94244-2430
1-866-741-6241 (Toll-Free)
SAWS 2 PLUS (4/15) PROGRAM RULES PAGE 4 OF 4
Work Rules for CalWORKs (Welfare-to-Work)
If you get cash aid, you must participate in Welfare-to-Work (WTW) unless you are exempt. The county will tell you if you
are exempt from WTW. If you do not do your assigned activities your cash aid may be lowered or stopped.
CalWORKs - Fingerprinting/Photo Imaging
All eligible adult household members for cash aid must be fingerprinted/photo-imaged. If anyone who is required to cooperate
with these rules does not get fingerprinted/photo-imaged, no benefits will be issued to the entire household. The
fingerprint/photo images are confidential and can only be used to prevent or prosecute welfare fraud.
How do I get/use my benefits?
CalFresh and Cash Aid:
• The County will mail or give you a plastic Electronic Benefit Transfer (EBT) card. Benefits will be put on the card when
your application is approved. Sign your card when you get it. You will set up a Personal Identification Number (PIN) to
get cash from ATMs or to buy food and/or other items.
• If your EBT card is lost, stolen, destroyed or you think someone may know your PIN number that you don’t want to use
your benefits call (877) 328-9677 or call the County right away to report it and change your PIN number. Make sure all
responsible adults and your authorized representative also know how to report one of these problems right away. Any
benefits taken from your account before you report the EBT card or PIN lost or stolen will NOT be replaced.
• You can use your CalFresh benefits to buy almost all foods, as well as seeds and plants to grow your own food. You
cannot buy alcohol, tobacco, pet food, some types of cooked food, or anything that is not food (like toothpaste, soap, or
paper towels).
• CalFresh benefits are accepted at most grocery stores and other places that sell food. Cash aid can be used at most
stores and most ATMs. Some ATMs may charge a fee. There may also be a fee if you use an ATM to get cash after
three withdrawals. For a list of locations near you that accept EBT, please go to: https://www.ebt.ca.gov or
https://www.snapfresh.org. You can also find out where you can get cash without paying a fee.
• CalFresh benefits are only for you and your household members. Your cash aid is only for you and the members of your
family who were approved for cash aid. Your cash aid is to help meet the basic needs of your family (housing, food,
clothing, etc.). Keep your benefits safe. Do not give out your PIN number. Do not keep your PIN number with your EBT
card.
• Any use of your EBT card by you, a household member, your authorized representative, or anyone you voluntarily give
your EBT card and PIN to will be considered approved by you and any benefits taken from your account will NOT be
replaced.
Medi-Cal and Health Care:
• For Medi-Cal, you will receive a Benefits Identification Card (BIC).
• Sign your BIC when you get it and use it only to get necessary health care services.
• Never throw your BIC away (unless we give you a new BIC). You need to keep your BIC even if you stop getting
Medi-Cal. You can use the same BIC if you get cash aid or Medi-Cal again.
• Take the BIC to your medical provider when you or a family member is sick or has an appointment.
• Take the BIC to the medical provider who treated you or your family member(s) in an emergency situation as soon
as possible after the emergency.
• For other health care programs you will receive a health plan card from your particular carrier.
General Assistance and General Relief:
• General Assistance and General Relief are County run programs for adults without children. The County will tell you
about your rights and responsibilities and the program rules if you are applying for one of these programs.
Please take and keep for your records
Are you homeless?
■
Yes
■
No If yes, please let the County know right away if you are homeless, so they can help you
figure out an address to use to accept your application and get notices from the county about your case.
What language do you prefer to read (if not English)?__________________________
What language do you prefer to speak (if not English)?_________________________
The County will provide an interpreter at no cost to you. If you are deaf or hard of hearing please check here
■
Please use black or blue ink because it is easy to read and copies best. Please print your answers.
If you need more space to answer a question(s), attach additional sheets of paper to provide the information. Please be sure to identify
which question you are writing about on the additional sheets of paper.
Does anyone in your household have a personal emergency?
■
Yes
■
No  If yes, check box:
■
Pregnancy
■
Immediate Medical Need 
■
Child Abuse
■
Domestic Abuse
■
Elder Abuse
■
Other emergency which
threatens health or safety. Explain:
SIGNATURE OF APPLICANT, CARETAKER RELATIVE (OR ADULT HOUSEHOLD MEMBER/ AUTHORIZED REPRESENTATIVE*/GUARDIAN)
*If you have an Authorized Representative, please complete Question 2 on the next page.
OTHER NAMES (MAIDEN, NICKNAMES, ETC.)
HOME PHONE
WORK/ALTERNATE/MESSAGE PHONE
EMAIL ADDRESS
SOCIAL SECURITY NUMBER (IF YOU HAVE
ONE AND ARE
APPLYING FOR BENEFITS)
NAME (FIRST, MIDDLE, LAST)
HOME ADDRESS OR DIRECTIONS TO YOUR HOME
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
APARTMENT #
APARTMENT #
CITY
CITY
COUNTY
COUNTY
STATE
STATE
ZIP CODE
ZIP CODE
I want to get information about this
application by email.
I want to get messages about my case by email.
■
Yes
■
No
■
Yes
■
No
What programs are you applying for?
■
CalFresh
■
Cash Aid
■
Health Coverage
■
Other_____________________________
Do you have a disability and
need help applying?
Is your household’s gross income less than
$150 and cash on hand, checking and
savings accounts $100 or less?
Is your household’s combined gross income
and liquid resources less than the combined
rent/mortgage and utilities?
Is your household a migrant/seasonal farm
worker household with liquid resources not
exceeding $100?
Do you have an eviction notice or a notice to
pay rent or leave
?
Have your utilities been shut off or do you have
a shut-off notice?
Will your food run out in 3 days or less?
Do you need essential clothing, such as
diapers or clothing needed for cold weather?
Do you need help with transportation to get
food, clothing, medical care or other
emergency item(s)?
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
Is anyone pregnant?
■
Yes
■
No  If yes, did she get a Presumptive Eligibility card?
■
Yes
■
No
I understand that by signing this application under penalty of perjury (making false statements), that:
• I read, or had read to me, the information in this application and my answers to the questions in this application.
• Any answers I have given on pages 1 through 17 and appendices A through E of the SAWS 2 Plus are true, correct, and
complete to the best of my knowledge.
• I read or had read to me and I understand and agree to the Rights and Responsibilities (Program Rules Page 1).
• I read, or had read to me, the Program Rules and Penalties (Program Rules Pages 2 - 4).
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility is
fraud and that I may be subject to penalties under federal law if I provide false or untrue information. Fraud can cause a criminal
case to be filed against me and/or I may be barred for a period of time (or life) from getting CalFresh benefits and cash aid.
• I understand that Social Security Numbers or Immigration Status for household members applying for benefits may be shared
with the appropriate government agencies as required by federal law.
• I am giving the Medi-Cal agency the right to pursue and get any money from other health insurance, legal settlements, or other
third parties.
SIGNATURE OF SPOUSE, OTHER PARENT, OTHER AIDED ADULT, OR REGISTERED DOMESTIC PARTNER
SAWS 2 PLUS (4/15)
PAGE 1 OF 17
DATE
DATE
1. APPLICANT’S INFORMATION
■
Yes
■
No
2. HOUSEHOLD’S AUTHORIZED REPRESENTATIVE
You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for
you at the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may
get by mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be
replaced. If you are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.
Do you want to name someone to help you with your CalFresh case?
■
Yes
■
No
If yes, complete the following section:
5. OTHER PROGRAMS
Has anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Tribal TANF, Medicaid,
Supplemental Nutrition Assistance Program [food stamps], General Assistance/General Relief, etc.)?
■
Yes
■
No
2a. HEALTH INSURANCE AUTHORIZED REPRESENTATIVES
You can give a trusted person permission to talk about your application for health insurance, see your information, and act for you
on things about this part of your application. Do you want to choose an authorized representative for the health insurance part of
your application?
■
Yes
■
No If yes, fill out the information in Appendix C.
SAWS 2 PLUS (4/15) PAGE 2 OF 17
AUTHORIZED REPRESENTATIVE NAME AUTHORIZED REPRESENTATIVE PHONE NUMBER
ETHNICITY
ARE YOU OF HISPANIC, LATINO, OR SPANISH ORIGIN?
■
Yes
■
No
3. Are you or any member of your family American Indian or Alaskan Native?
■
Yes
■
No
If yes, and applying for health care, please go to Appendix B for additional questions.
IF YOU ARE OF HISPANIC, OR LATINO ORIGIN, DO YOU CONSIDER YOURSELF
■
Mexican
■
Puerto Rican
■
Cuban
■
Other________________
NAME
ADDRESS CITY, STATE, ZIP CODE
PHONE NUMBER
Do you want to name someone to receive and spend CalFresh Benefits for your household?
■
Yes
■
No
If yes, complete the following section:
4. INTERVIEW PREFERENCE
You will need to have an interview with the County to discuss your application and to receive cash aid or CalFresh benefits.
Interviews for CalFresh are usually done by phone, unless you can be interviewed when giving your application to the County
in person or would prefer an in-person interview. Cash aid applicants must have an in person interview. If you are applying for
CalWORKs and CalFresh, your CalFresh interview will be done at the same time as your CalWORKs interview during normal office
hours.
■
Please check this box if you would prefer an in-person interview for CalFresh.
■
Please check this box if you need other arrangements due to a disability.
IF YES, WHO? WHERE (COUNTY/STATE)?
IF YES, WHO? WHERE (COUNTY/STATE)?
RACE/ETHNICITY
Race and ethnicity information is optional. It is requested to assure that benefits are given without regard to race, color, or national
origin. Your answers will not affect your eligibility or benefit amount. Check all that apply to you. The law says the County must
record your ethnic group and race.
■
Check this box if you do not want to give the County information about your race and ethnicity. If you do not, the County will
enter this information for civil rights statistics only.
RACE/ETHNIC ORIGIN
■
White 
■
American Indian or Alaskan Native 
■
Black or African American 
■
Other or Mixed _________________
■
Asian (If checked, please select one or more of the following):
■
Filipino 
■
Chinese 
■
Japanese 
■
Cambodian 
■
Korean 
■
Vietnamese 
■
Asian Indian 
■
Laotian 
■
Other Asian (specify)__________________
■
Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following):
■
Native Hawaiian 
■
Guamanian or Chamorro 
■
Samoan
6. HOUSEHOLD’S INFORMATION: ADULTS
6a. Does everyone listed in question 6 have the same contact information?
■
Yes
■
No If no, please fill in the person’s contact information below.
If yes, please skip to the next question.
Complete the following information for all adults in the home. If applying for health care coverage, also include any adults claimed on
your tax return.
If you are applying for cash aid and there is more than one adult in the home who is applying for cash aid or who is the parent of a
child applying for aid, please go to Appendix D for additional questions.
For noncitizens you are applying for, please complete additional questions 6e and 6f.
APPLYING
FOR
BENEFITS
(check each
type)
CalFresh
Single
Married
Separated
Divorced
Widowed
Full-Time Student (check if yes)
Disabled (check if yes)
*Cash Aid
Medi-Cal
Health Care
None
How is the
person
related to
you?
DATE
OF BIRTH
GENDER
(M OR F)
Marital Status
NAME
(Last, First, Middle Initial)
Only answer the
question below for
each person applying
for benefits.
U.S.
CITIZEN or
NATIONAL (check
Yes or No)
If no, complete
question 6e.
Social Security
number is optional
for members not
applying for benefits.
SOCIAL SECURITY
NUMBER
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Yes
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No
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Yes
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No
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Yes
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No
■
Yes
■
No
■
Yes
■
No
NAME (FIRST, MIDDLE, AND LAST)
HOME PHONE NUMBER
WORK/ALTERNATE/MESSAGE PHONE
HOME (STREET) ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
EMAIL ADDRESS (OPTIONAL)
APARTMENT #
APARTMENT #
CITY
CITY
STATE
STATE
ZIP CODE
ZIP CODE
NAME (FIRST, MIDDLE, AND LAST)
HOME PHONE NUMBER
WORK/ALTERNATE/MESSAGE PHONE
SAWS 2 PLUS (4/15) PAGE 3 OF 17
HOME (STREET) ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
EMAIL ADDRESS (OPTIONAL)
APARTMENT #
APARTMENT #
CITY
CITY
STATE
STATE
ZIP CODE
ZIP CODE
* Cash Aid also includes General Assistance and General Relief programs.
6b. HOUSEHOLD’S INFORMATION: CHILDREN
6c. SOCIAL SECURITY INFORMATION
Does everyone applying for aid have a Social Security Number?
■
Yes
■
No
If no, please fill in the information below.
We need the Social Security Number for everyone who is applying for aid. There are some exceptions for people who are victims of domestic violence
or other crimes such as human trafficking. If you need help getting a Social Security Number call 1-800-772-1213 or go online to www.socialsecurity.gov
.
Complete the following information for all children in the home. If applying for health care coverage, also include any children
claimed on your tax return.
For noncitizens you are applying for, please complete additional questions 6e and 6f.
APPLYING
FOR
BENEFITS
(check each
type)
CalFresh
Not in home
Unemployed
Disabled
Deceased
None
Full-Time Student (check if yes)
Shots up to date? (check if yes)
Cash Aid
Medi-Cal
Health Care
None
How is the
person
related to
you?
DATE
OF BIRTH
PLACE
OF
BIRTH
SEX
(M / F)
Check all that
applies to one or
both of the child’s
parents
NAME
(Last, First, Middle Initial)
Only answer the
question below for
each person
applying for
benefits.
U.S.
CITIZEN or
NATIONAL (check
Yes or No)
If no, complete
question 6e.
Social Security
number is optional
for members not
applying for benefits.
SOCIAL SECURITY
NUMBER
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■
■
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Yes
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No
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Yes
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No
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Yes
■
No
■
Yes
■
No
■
Yes
■
No
SAWS 2 PLUS (4/15) PAGE 4 OF 17
NAME REASON FOR NOT HAVING A SOCIAL SECURITY NUMBER
APPLIED FOR SSN
■
The person is a child who is less than one year old.
■
It is against this person’s religion.
■
This person does not qualify for an SSN.
■
Other ___________________________________________________
■
The person is a child who is less than one year old.
■
It is against this person’s religion.
■
This person does not qualify for an SSN.
■
Other ___________________________________________________
Has this person applied
for a Social Security
Number?
■
Yes
■
No
Has this person applied
for a Social Security
Number?
■
Yes
■
No
SAWS 2 PLUS (4/15)
PAGE 5 OF 17
6d. Has anyone been in the U.S. Military service or are they the spouse,
parent or child of a person who was?
■
Yes
■
No
If yes, please complete the information below. If no, please continue to the next question.
Name
U.S.
Citizen?
(
✔
) Status
Honorable
Discharge?
Dates of Service
Name
Date
entered U.S.
(if known)
Does this person have an eligible
immigration status? If yes, please
provide their immigration document
and number.
Has this person
lived in the U.S.
continuously
since 1996?
Is this person
a Naturalized
Citizen?
Sponsored?
(check Yes or No)
If yes, complete
question 6f
■
Active duty
■
Veteran
■
Spouse, parent, or child of
person in active duty or a
veteran
■
Active duty
■
Veteran
■
Spouse, parent, or child of
person in active duty or a
veteran
6e. NONCITIZEN INFORMATION - Please complete for noncitizens you are applying for.
DOCUMENT TYPE:
DOCUMENT NUMBER:
DOCUMENT TYPE:
DOCUMENT TYPE:
DOCUMENT NUMBER:
DOCUMENT NUMBER:
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
Does anyone listed above have at least 10 years (40 quarters) of work history?
■
Yes
■
No
If yes, who? ___________________________________________
Does anyone listed above have, or have they applied for, or do they plan to apply for a T-Visa or U-Visa,
■
Yes
■
No
VAWA petition?
If yes, who? __________________________________________
Has anyone changed their immigration status in the last 12 months?
■
Yes
■
No
If yes, please complete the information below.
If no, please continue to the next question.
NAME
NAME
WHAT CHANGED?
WHAT CHANGED?
DATE OF CHANGE
DATE OF CHANGE
ALIEN NUMBER (IF APPLICABLE)
ALIEN NUMBER (IF APPLICABLE)
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
SAWS 2 PLUS (4/15)
PAGE 6 OF 17
6f. Sponsored Noncitizen Information - Please answer for sponsored noncitizens you are applying for.
Did the sponsor sign an I-864?
■
Yes
■
No If yes, please answer the rest of the question.
If the sponsor signed an I-134 then skip this question.
6g. Does anyone listed in question 6 who is under the age of 21 have a parent who does not live in the home?
■
Yes
■
No If yes, please list the name of the child(ren) and the name(s) of the parents who do not live in the home.
If no, please continue to the next question.
6h. Does anyone in question 6 live with at least one child under the age of 19 and are they the main person taking care
of the child?
■
Yes
■
No If no, skip to the next question. If yes, who?___________________________________________________
6i. Does anyone listed in question 6 have a physical, mental, emotional, or developmental disability that causes
limitations in activities (such as bathing, dressing, daily chores)?
■
Yes
■
No If yes, please list the name(s) of the
person with the disability. If no, please continue to the next question.
Name:____________________________________________ Name:________________________________________
6j. Complete for each disabled person listed in question 6.
Does this person need care so that someone else can
work or attend school?
■
Yes
■
No
Does this person need help with activities of daily living through personal assistance or
a medical facility?
■
Yes
■
No
If yes, explain:
Does this person work and have medical expenses that are needed to help them keep
working? For example, a wheelchair, leg braces, etc.
■
Yes
■
No If yes, please explain.
Is this person in a medical facility or nursing home?
■
Yes
■
No
If yes, what is the name of the medical facility or nursing home?
Does the sponsor regularly help with money?
■
Yes
■
No If yes, how much? $ _________
Does the sponsor regularly help with any of the following (check all that apply)?
■
rent
■
clothes
■
food
■
other________________________________________________________________
SPONSOR’S NAME
SPONSOR’S NAME
NAME OF CHILD
NAME OF CHILD
NAME OF PARENT(S) NOT LIVING IN THE HOME
NAME OF PARENT(S) NOT LIVING IN THE HOME
WHO IS SPONSORED?
WHO IS SPONSORED?
SPONSOR’S PHONE NUMBER
SPONSOR’S PHONE NUMBER
Name of person
Disability is expected to last:
■
30 days or more
■
12 months or more
Does this person need care so that someone else can
work or attend school?
■
Yes
■
No
Does this person need help with activities of daily living through personal assistance or
a medical facility?
■
Yes
■
No
If yes, explain:
Does this person work and have medical expenses that are needed to help them keep
working? For example, a wheelchair, leg braces, etc.
■
Yes
■
No If yes, please explain.
Is this person in a medical facility or nursing home?
■
Yes
■
No
If yes, what is the name of the medical facility or nursing home?
Name of person
Disability is expected to last:
■
30 days or more
■
12 months or more
6k. Is there a child or disabled person in the household who needs care from another household member?
■
Yes
■
No If yes, please explain. If no, skip to the next question.
SAWS 2 PLUS (4/15)
PAGE 7 OF 17
6l. Students
Is anyone who is applying for benefits attending a college or vocational school?
■
Yes
■
No
If yes, please answer this queston. If no, skip to the next question.
6m. Is anyone listed in question 6 or 6b pregnant or a teen parent?
■
Yes
■
No
If yes, please answer the question. If no, skip to the next question.
6n. Has anyone ever gotten a cash bonus or penalty, or help with child care, transportation or other service from the
Cal-Learn Program?
■
Yes
■
No
If yes, please answer the question. If no, skip to the next question.
6o. Was anyone listed in question 6 ever in foster care?
■
Yes
■
No
If yes, please explain.
School status if under the age of 20
■
Has a high school diploma
■
Has a GED
■
Is attending school regularly
■
Is not attending school
regularly (explain why):
School status if under the age of 20
■
Has a high school diploma
■
Has a GED
■
Is attending school regularly
■
Is not attending school
regularly (explain why):
■
Half-time or more
■
Less than half-time
Number of Units:________
■
Half-time or more
■
Less than half-time
Number of Units:________
Name of Person
Name
Name
Name
Name:
When:
State:
Name:
When:
State:
Is this person 26 years of age or
younger and were they in foster
care on their 18th birthday?
■
Yes
■
No
Is this person 26 years of age or
younger and were they in foster
care on their 18th birthday?
■
Yes
■
No
Where (County)
Date(s) Received
Name of School/Training
Enrolled Status
(
✔
check one)
Working?
Average work hours
per week: _______
Average work hours
per week: _______
Is this person under the age of 20?
■
Yes
■
No
Is this person a teen parent?
■
Yes
■
No
Is this person under the age of 20?
■
Yes
■
No
Is this person a teen parent?
■
Yes
■
No
Due date
(if known)
Due date
(if known)
How many
babies are
expected
with this
pregnancy?
How many
babies are
expected
with this
pregnancy?
SAWS 2 PLUS (4/15)
PAGE 8 OF 17
6p. Is there a foster child currently living in your home who is receiving foster care services?
■
Yes
■
No
If yes, who?_________________________
Please answer the following questions about the foster child(ren):
6q. Does everyone listed in question 6 live in California and expect to keep living here?
■
Yes
■
No
If no, please explain.
6r. Does anyone listed in question 6 plan to leave California for more than 30 days?
■
Yes
■
No
If yes, please explain.
NAME
NAME
WHEN DO THEY PLAN TO LEAVE?
WHEN DO THEY PLAN TO LEAVE?
DOES THIS PERSON PLAN TO RETURN TO CALIFORNIA?
■
YES
■
NO IF YES, WHEN:
DOES THIS PERSON PLAN TO RETURN TO CALIFORNIA?
■
YES
■
NO IF YES, WHEN:
Person Getting the Money?
From Where?
How Much?
How Often Received?
(once, weekly,
monthly, or other)
Expect to
Continue?
(Check Yes or No)
Was this child(ren) placed in your home under a dependency order of the court?
■
Yes
■
No
Do you want the foster care child(ren) counted in your CalFresh case?
■
Yes
■
No
If yes, the foster care income you receive will be counted as unearned income.
If no, the foster care income will not be counted as unearned income.
Check all types of unearned income that apply from these examples (there may be others not listed here):
■
Social Security Disability
■
SSI/SSP
■
Cash aid
■
CalWORKs/TANF/GA/GR/CAPI/RCA
■
Room and board (from a renter)
■
Pension
■
Child/Spousal support
■
Rental/Royalties
■
Social Security retirement
or survivors benefits
■
Per capita payments
■
Work study/welfare to work or
other program
■
Sales of notes, contracts, trust deeds,
promissory notes
■
Veterans education benefits/income
■
Government/railroad disability or retirement
■
Veteran benefits or Military pension
■
Financial aid (school grants/loans/scholarships)
■
Gifts of money or other loans
■
Unemployment Insurance/
State Disability Insurance (SDI)
■
Worker’s Compensation
■
Net Farming/Fishing
■
Lottery/gambling winnings
■
Help with rent/food/clothing
■
Insurance or legal settlements
■
Private disability or retirement
■
Dividend and interest income
■
Strike benefits
■
Other____________________
________________________
If this income is not expected to continue, please explain:
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
7. Unearned Income
Does anyone get income that does not come from work (unearned)?
■
Yes
■
No If yes, please answer this question.
If no, skip to the next question.
SAWS 2 PLUS (4/15)
PAGE 9 OF 17
8. Earned income
Does anyone get income from a job (earned income)?
■
Yes
■
No If yes, please answer this question.
If no, skip to the next question.
NOTE: If self-employed, fill out question 8a below.
Please list all income before taxes or other deductions are taken out (gross income).
Examples of earned income are (these examples can be full-time, temporary seasonal work, or training, and there may be
others not listed here):
● Wages ● Commissions ● Tips ● Salaries ● Work study (students)
● Include any paid jobs the County helped you get.
8a. Self-Employment
Self-employed household members may take actual self-employment expenses (or for CalFresh or cash aid, take a standard
40% deduction off of self-employment income). For cash aid, you may also choose to use a monthly average (yearly business
costs divided by 12 months). If you choose actual expenses, you must list your business expenses on a separate sheet of
paper.
Person Working
Employer’s Name
and Address
Employer’s
Phone Number
Hourly
Rate
*Net
Monthly
lncome
Gross
Monthly
Income
Date
Business
Started
Type of
Business
Business
Name
Person
Self-Employed
Average
hours per
week
How Often
Paid?
(Once weekly,
monthly, other)
Total Gross
Earned
Income
Received
This
Month?
Expect to
Continue?
(✔ Check
Yes or No)
If this income is not expected to continue, please explain:
$
$
$
$
$
$
$
$
$
$
$
$
$
$
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
Has anyone lost a job, changed jobs, quit a job, or reduced work hours within the last 60 days?
■
Yes
■
No
In the last year?
■
Yes
■
No
Did the County help the person get this job?
■
Yes
■
No
IF YES, WHO?
DATE OF JOB LOSS,
QUIT, OR CHANGE
IF YES, WHO? DATE WENT ON
STRIKE
DATE OF LAST PAY
REASON?
DATE OF LAST PAY
REASON?
IS ANYONE ON STRIKE?
■
Yes
■
No
Self-Employment Expenses
(please ✔ check one)
■
40% flat Rate (CalFresh/cash aid)
■
Actual Expenses $ ___________
■
Monthly Average $ ___________
■
40% flat Rate (CalFresh/cash aid)
■
Actual Expenses $ ___________
■
Monthly Average $ ___________
■
40% flat Rate (CalFresh/cash aid)
■
Actual Expenses $ ___________
■
Monthly Average $ ___________
* Net monthly income is gross monthly income
minus expenses.
SAWS 2 PLUS (4/15)
PAGE 10 OF 17
9. Other Income
Does anyone get housing or rent, utilities, food or clothing free or in exchange for work?
■
Yes
■
No
If yes, please answer this question.
If no, skip to the next question.
10. Yearly Income
Does anyone’s total income (unearned, earned, and self employment) change from month to month?
■
Yes
■
No
If yes, please answer this question.
If no, skip to the next question.
11. Household’s Child/Adult Care Expenses (The actual amount of cost incurred if allowing the expenses to potentially
be a deduction).
Does anyone pay for care of a child, disabled adult, or other dependent so you or the other person can go to work, school, or
look for a job?
■
Yes
■
No If yes, please answer this question.
If no, skip to the next question.
12. Child Support Payments
Is anyone listed in question 6 legally obligated to pay child support, including back child support?
■
Yes
■
No
If yes, please answer this question.
If no, skip to the next question.
Item Received
Free
For
Work
Who gets the item?
Name of Person
What will be their total income
this year?
What will be their total income next year
(if you think it will be different)?
How Often Paid?
(weekly/monthly, other)
How Often Paid?
(weekly/monthly, other)
How Often?
(weekly/monthly, other)
Amount
paid?
Amount
paid?
Amount
paid?
Who gives care?
(name and address of provider)
Who helps pay?
Name of child(ren) for whom
child support is paid:
Who gets care?
Who gets care?
Who pays child support?
Value Who gives the item?
$
$
$
$
$
$
$
$
■
■
■
■
■
■
■
■
$
$
$
$
$
$
$
$
Housing or Rent
Utilities
Food
Clothing
Does anyone help your household pay all or part of your child/adult care cots listed above?
■
Yes
■
No If yes, complete below.
SAWS 2 PLUS (4/15)
PAGE 11 OF 17
13. Spousal Support/Alimony
Is anyone listed in question 6 legally obligated to pay spousal support/alimony?
■
Yes
■
No
If yes, please answer the questions below.
If no, skip to the next question.
14. Special Needs Expenses
Does anyone have a special medical condition or situation that requires any of the following?
Special diet prescribed by a doctor?
■
Yes
■
No
Special phone or other equipment?
■
Yes
■
No
Housework (no one in the home can do it)?
■
Yes
■
No
Very high use of utilities?
■
Yes
■
No
Special laundry service?
■
Yes
■
No
15. Household Expenses
Does anyone you purchase and prepare food with get billed for any household expenses?
■
Yes
■
No
If yes, please answer this question.
If no, skip to the next question.
NOTE: Do no enter amounts paid by housing assistance such as HUD or Section 8. The heating and cooling, telephone,
other utilities, and the homeless shelter are set allowances. It is not necessary to fill in the actual amount owed.
Who pays spousal support/alimony?
Amount paid?
How Often Billed?
(weekly/monthly)
Amount
Owed
How much? How often paid?Who helps pay?
Have
Expense?
Who Pays?
Type of Expenses
Rent or house payment
Property taxes and insurance
(if billed separate from rent or mortgage)
Gas, electric, or other fuel used for heating
or cooling, such as firewood or propane
(if separate from rent or mortgage)
Telephone/cell phone
Homeless Shelter Expense
Water, sewage, garbage
Does anyone not in your household help you
pay for the expenses listed above?
■
Yes
■
No If yes, please complete.
Does your household get, or expect to get any payments from the
Low Income Home Energy Assistance Program (LIHEAP)?
■
Yes
■
No
How often?
(weekly, bi-weekly. monthly, other)
$
$
$
$
$
Other special need? (specify)
■
Yes
■
No
_______________________________________________________
Please list the name of the person with the special need and explain:
_______________________________________________________
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
SAWS 2 PLUS (4/15) )
PAGE 12 OF 17
16. Medical Expenses:
Are you or anyone you buy and prepare food with an elderly (60 or older) or disabled person that has any out-of-pocket
medical expenses?
■
Yes
■
No
If yes, please answer this question.
If no, skip to the next question.
NOTE: Do not list spouses or children receiving dependent payments for an SSI or disability and blindness recipient.
List expenses you expect to have in the near future.
Allowable medical expenses are:
■
Medical or dental care
■
Hospitalization/outpatient
treatment/nursing care
■
Prescribed medications
■
Health and Hospitalization
insurance policy premiums
17. Other Tax-Deductible Expenses
If anyone pays for anything that can be deducted on a federal income tax return, telling us about it here could make the cost of
health insurance a little lower. Do not include anything that you already included in self-employment expenses. If you have
other deductible expenses, please answer this question. If no, skip to the next question.
18. Does anyone in question 6 get food from any of the following?
■
Yes
■
No
If yes, please answer this question. If no, skip to the next question.
● Communal dining facility for the elderly/disabled ● Food distribution program operated ● Other food program
by a Native American reservation
19. Does anyone in question 6 live at any of the following?
■
Yes
■
No
If yes, please answer this question. If no, skip to the next question.
● Homeless Shelter
● Shelter for battered women
● Reservation for Native Americans
● Drug/Alcohol rehabilitation center
● Correctional facility/Penal institution (Jail or Prison)
Name of Elderly/Disabled Person
Amount of
Expense
How often paid?
(monthly, weekly,
other)
What type of
expense?
(prescriptions,
dentures, # of meals
for attendant, etc.)
Will the household be reimbursed
for any medical expenses?
(by Medi-Cal, insurance,
family member, etc.)
$
$
■
Medicare premiums (Medi-Cal share of
costs, etc.)
■
Dentures, hearing aids and prosthetics
■
Maintaining an attendant necessary due
to age, illness, or infirmity
■
The number and cost of meals
furnished to an attendant
■
Prescribed over the counter medications
■
Cost of transportation (mileage or fee)
and lodging to obtain medical treatment
or services
■
Prescribed eye glasses and contact
lenses
■
Prescribed medical supplies and
equipment
■
Service animals expenses
(food, vet bills, etc.)
IF YES, BY WHO:
HOW MUCH: $
IF YES, BY WHO:
HOW MUCH: $
Type of Expenses
Alimony
Student loan interest
Other deductions (please identify)
Have Expense?
Who pays?
How often paid?
(weekly/monthly)
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
IF YES, WHO?
IF YES, WHO?
WHAT PROGRAM?
WHAT PROGRAM?
● Group living arrangement for the blind/disabled
● Federally subsidized housing
● Psychiatric hospital/mental institution
● Hospital
● Long-Term Care or Board and Care Facility
Person’s Name
Name of Institution (Center, Shelter, Facility, etc.)
Expected Date of Release
(if applicable)
SAWS 2 PLUS (4/15)
PAGE 13 OF 17
20. Is anyone getting In-Home Supportive Services (IHSS)?
■
Yes
■
No
If yes, fill in the information below.
21. Does everyone listed in question 6 buy and prepare food with you?
■
Yes
■
No
If no, list the people who don’t buy and prepare food with you.
22. Answer these questions for anyone who needs health coverage. Is anyone enrolled in health coverage now from
the following?
■
Yes
■
No
If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.
21a. Is anyone living with you age 60 or older and unable to buy food and fix meals separately because of a disability?
■
Yes
■
No If yes, who:________________________________________________________________________
22a. Is anyone listed on this application offered health care coverage from a job?
■
Yes
■
No
If yes, you’ll need to complete and include Appendix A.
22b. Is anyone’s health insurance expected to end or has it ended in the last 90 days?
■
Yes
■
No
If yes, please answer the question. If no, skip to the next question.
22c. Does anyone want help for medical bills from the last three months?
■
Yes
■
No
If yes, who:_____________________________________________________________________________________
23. Does anyone listed in question 6 plan to file a federal income tax return next year?
■
Yes
■
No
If yes, complete the questions below for each tax filer.
If no, skip to 23f.
23a. Please complete this section for each person who plans to file a federal income tax return next year if you answered yes to
question 23. You can still apply for health insurance even if you don’t file a federal income tax return.
23b. Name of person planning to file a federal income tax return:__________________________________________________
23c. Will this person file jointly with a spouse?
■
Yes
■
No
If yes, name of spouse:_______________________________________________________________________________
23d. Will this person claim any dependents on their tax return:
■
Yes
■
No
If yes, please list the name(s) of the dependents you are claiming:_____________________________________________
23e. How is the dependent(s) listed in 23d related to the tax filer who will claim them?:_________________________________
23f. To make it easier to determine my eligibility for paying health coverage in future years. I agree to allow you to use income
data, including information from tax returns. You will send me a notice, let me make any changes, and I can opt out at any
time.
Yes, renew my eligibility automatically for the next (check one):
■
5 years
■
4 years
■
3 years
■
2 years
■
1 year
■
No, don’t use information from tax returns to renew my coverage.
WHO GETS SERVICES?
HOW MUCH DO YOU PAY EACH MONTH FOR THE SERVICES?
$
NAME
NAME
NAME
NAME
■
Medicaid/Medi-Cal
■
CHIP
■
Medicare
■
TRICARE (Don’t check if you have direct
care or Line of Duty)
■
VA health care programs
■
Peace Corps
■
Employer Insurance
■
Other
Name of health insurance
Policy Number:
Is this plan a limited-benefit plan
like a school accident policy?
■
Yes
■
No
Name of health insurance
Policy number:
Is this COBRA coverage?
■
Yes
■
No
Is this a retiree health plan?
■
Yes
■
No
Is this a state employee benefit plan?
■
Yes
■
No
Insurance Company
Person Insured
Expiration
Date
Reason it ended or will end
Have you or anyone in your household sold, traded, given away, or transferred a resource in the last thirty (30) months?
■
Yes
■
No
If you traded or gave the resource away, please explain:_______________________________________________________________
___________________________________________________________________________________________________________
SAWS 2 PLUS (4/15)
PAGE 14 OF 17
24. Household’s Resources
Does anyone have any resources (cash, money in the bank, Certificate of Deposit,
stocks and bonds, etc.)?
■
Yes
■
No If yes, please answer this question. If no, skip to the next question.
25. Personal Property
Does anyone own any personal or business-related property?
■
Yes
■
No
If yes, please answer the question. If no, skip to the next question.
Check each resource listed below that you or anyone in your household has:
If joint account with another person please say so below.
For each box checked above, complete the following information.
■
Bank/Credit Union account (Checking)
■
Bank/Credit Union account (Savings)
■
Safe Deposit box
■
Savings Bond(s)
■
Oil, Mining or Mineral Rights
■
Money Market Account(s)
■
Mutual funds/Trust funds
■
Certificate of Deposit (CD)/IRA
■
Cash on hand
■
Notes, Mortgages, Deeds of Trust
■
Tools
■
Business inventory
■
Livestock
■
Business equipment
■
Sporting equipment, Guns
■
Non-Motor boats and/or trailers
■
Camper shells
■
Personal tools
■
Jewelry, Artwork, Antiques, Collections, Musical instruments (Piano, Organ, etc.)
■
Stocks
■
Bonds
■
Uncashed checks
■
Life or Burial insurance
■
Other: ____________________
In Whose Name is the
Resource Listed?
Type of Resource
How Much is
it Worth?
Where is the Resource? (include the name of the bank or
company where money is held)
$
$
$
$
WHEN?
WHAT WAS THE RESOURCE? WHAT WAS IT WORTH?
$
HOW MUCH DID YOU GET
FOR IT
$
Please include the item even if it is jointly owned with someone else. Do not include wedding or engagement rings, family heirlooms, etc.
List any other jewelry worth $100 or more and household goods or personal items worth more than $500 per item.
Item
Is it listed for
Sale?
Purchase Price or Current Value
Amount Owed
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Optional for health care; only answer if someone applying is 65 or older or disabled. If applying for cash aid and CalFresh, you
must answer the question.
Optional for health care; only answer if someone applying is 65 or older or disabled.
SAWS 2 PLUS (4/15)
PAGE 15 OF 17
26. Vehicles
Does anyone own, have the use of, or have their name on any registration of any motor vehicle, such as: a car, motorcycle,
snowmobile, recreational vehicle (RV), or motorboat, etc., even if it isn’t running?
■
Yes
■
No
If yes, please fill out the information in Appendix E.
$
$
$
$
Who owns or is buying the
home/property?
Address of the home/property
Is someone
renting the
home from the
owner?
How much rent does
the owner get?
Not living in
now but owner
expects to move
back into the
home someday?
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Not
rented
■
Not
rented
27. Does anyone in question 6 own or are they buying a home, land, or property anywhere including in another state
or country?
■
Yes
■
No If yes, please explain.
28. Diversion Program
Has anyone received a Diversion cash payment or non-cash services from any county or other state?
■
Yes
■
No
If yes, please answer the question. If no, skip to the next question.
Name
County/State
Received From
List of Services Received
Amount
Received
Date Last
Received
Estimated
Value of
Services
Optional for health care; only answer if someone applying is 65 or older or disabled. If you are applying for cash aid, you must
answer the question.
Optional for health care; only answer if someone applying is 65 or older or disabled.
29. Duplicate Benefits
Have you, or any member of your household been convicted of fraudulently receiving duplicate SNAP
(federal name for food assistance program) benefits in any State after September 22, 1996?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
30. Trafficking Benefits
Have you, or any member of your household, ever been convicted of trafficking (allowing use of or selling EBT cards to
others) SNAP benefits of $500 or more after September 22, 1996?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
31. Trading Benefits for Drugs
Have you or any member of your household been found guilty of trading SNAP benefits for drugs after
September 22, 1996?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
32. Trading Benefits for Firearms or Explosives
Have you or any member of your household been found guilty of trading SNAP benefits for guns, ammunition or explosives
after September 22, 1996?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
33. Fraud
Have you or anyone in your household had their cash aid stopped for being found guilty of Welfare Fraud?
■
Yes
■
No
If yes, who?____________________________________________ When?_____________________________________
Where? ___________________________________________________________________________________________
34. Non-Cooperation/Sanctions
Have you or anyone in your household had their cash aid stopped for failure to cooperate with eligibility requirements,
work/training sanctions or any other reason?
■
Yes
■
No
If yes, who?____________________________________________ When?_____________________________________
Where? _____________________________________________Why?__________________________________________
SAWS 2 PLUS (4/15)
PAGE 16 OF 17
35. Fleeing Felon
Are you or any member of your household 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?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
36. Probation/Parole Violation
Have you or any member of your household been found by a court of law to be in
violation of probation or parole?
■
Yes
■
No
If yes, who?________________________________________________________________________________________
A. Regular check-ups to help protect your family’s health are available upon request through the Child Health and Disability
Prevention Program (CHDP) for eligible members of your family under age 21.
● Do you want more information about CHDP services?
■
Yes
■
No
● Do you want CHDP medical services?
■
Yes
■
No
● Do you want CHDP dental services?
■
Yes
■
No
● Do you need help making appointments or with transportation to CHDP services?
■
Yes
■
No
B. Do you want more information about immunization services?
■
Yes
■
No
C. If you are pregnant, you can get help finding a doctor, getting healthy foods and other help.
Do you want to talk to someone about this help?
■
Yes
■
No
D. Are you breastfeeding a child?
■
Yes
■
No
If yes, have you given birth within the last 12 months?
■
Yes
■
No
If you checked yes to 38 C or D, you may be eligible for services provided by 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 help plan
how to prevent unwanted pregnancies and/or have the next child?
■
Yes
■
No
If yes, call your health care plan or regular doctor. Or, for facts and the location of
confidential family-planning clinics, call toll-free 1-800-942-1054.
37. Other Special Needs
Does the household want to apply for a special need payment for housing or essential household items lost or damaged
due to sudden and/or unusual circumstances, such as a fire, earthquake, or flood?
■
Yes
■
No
If yes, please explain:
38. Other Services
The following services are available. Your answers to the questions will not affect your eligibility.
Additional Writing Space
39. Third Party Liability
Is anyone who is applying for healthcare involved in a worker’s compensation claim,
lawsuit, or settlement because of an accident or injury?
■
Yes
■
No
If yes, please tell us who:
SAWS 2 PLUS (4/15)
PAGE 17 OF 17
Additional Writing Space
DO NOT COMPLETE - COUNTY USE ONLY
IF THE ANSWER IS “YES” TO ANY OF THE QUESTIONS BELOW - EXPEDITE
Is the household’s gross income less than $150 and is the total of cash on hand, checking and
savings accounts $100 or less?
■
Yes
■
No
Is the household’s combined gross income and liquid resources less than the combined
rent/mortgage and appropriate utility allowance?
■
Yes
■
No
Is the household a destitute migrant/seasonal farm worker household with liquid resources
not exceeding $100?
■
Yes
■
No
Does the CalWORKs Assistance Unit have a pay-or-quit or other eviction notice?
■
Yes
■
No
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next three
months?
■
No (stop here for this section of the application)
■
Yes (continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage? ___________________
List the names of anyone else who is eligible or will be eligible for coverage from this job.
Name:_________________________ Name:________________________Name:________________________
Tell us about the health plan offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?
■
Yes
■
No
14a. Is this a State employee benefit plan?
■
Yes
■
No
15. For the lowest-cost plan that meets the minimum value standard offered only to the employee
(don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/she received the
maximum discount for any tobacco cessation (that helps the employee to quit smoking) programs, and did not receive
any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $____________
b. How often?
■
Weekly
■
Bi-weekly
■
Twice a month
■
Monthly 
■
Quarterly 
■
Yearly
■
The employer doesn’t offer wellness programs.
16. What change will the employer make for the new plan year (if known)?
■
Employer will no longer provide health coverage.
■
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard.
a. How much would the employee have to pay in premiums for this plan? $____________
b. How often?
■
Weekly
■
Bi-weekly
■
Twice a month
■
Monthly 
■
Quarterly 
■
Yearly
c. Date of change (mm/dd/yyyy):________________________________
■
No changes are expected.
*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs
covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
SAWS 2 PLUS (4/15)
APPENDIX A
Appendix A HEALTH COVERAGE FROM JOBS
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. If
there is more than one person who is offered health coverage from a different employer, you can copy this page and use it
for the second person (or as many as you need).
First, tell us about the job (employer) who offers coverage.
1. EMPLOYEE NAME (FIRST NAME, MIDDLE NAME, LAST NAME)
3. EMPLOYER NAME
5. EMPLOYER ADDRESS
7. CITY
10. WHO CAN WE CONTACT ABOUT EMPLOYEE HEALTH COVERAGE AT THIS JOB?
11. PHONE NUMBER (IF DIFFERENT FROM EMPLOYER’S PHONE NUMBER)
( )
12. EMPLOYER’S EMAIL ADDRESS (EMPLOYER’S REPRESENTATIVE)
8. STATE
(MM/DD/YYYY)
9. ZIP CODE
6. EMPLOYER PHONE NUMBER
( )
2. EMPLOYEE SOCIAL SECURITY NUMBER
__ __
4. EMPLOYER IDENTIFICATION NUMBER (EIN)
__
EMPLOYER Information
SAWS 2 PLUS (4/15)
APPENDIX B
Appendix B QUESTIONS FOR AMERICAN INDIAN AND ALASKAN NATIVE INDIVIDUALS
Complete this section if you or a family member (spouse and/or dependents) are American Indian or Alaskan Native. Submit
this with your application.
Tell us about your American Indian or Alaskan Native family member(s).
American Indians and Alaskan Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. They also may not have to pay a cost share and may get special monthly enrollment periods. Answer
the following questions to make sure your family gets the most help possible. If you have more than two people to tell us
about, make a copy of this page and attach it. You may also use a separate piece of paper. Just remember to write the
question number next to your answer.
1. Name (First name, Middle name, Last name)
2. Member of a federally recognized tribe?
3. Has this person ever gotten a service from the
Indian Health Service, a tribal health program,
or through a referral from one of these
programs?
4. Certain money may not be counted for Medicaid
or the Children’s Health Insurance Program
(CHIP). List any income (amount and how
often) reported on your application that includes
money from these sources:
● Per capita payments from a tribe that
comes from natural resources, usage
rights, leases, or royalties
● Payments from natural resources, farming,
ranching, fishing, leases or royalties from
land designated as Indian trust land by the
Department of the Interior (including
reservations and former reservations)
● Money from selling things that have cultural
significance
First Middle First Middle
Last Last
■
Yes
If yes, tribe name
___________________________
■
No
■
Yes
If yes, tribe name
___________________________
■
No
■
Yes
■
No
If no, is this person eligible to get
services from the Indian Health
Services, tribal health program,
urban Indian health programs or
through a referral from one of these
programs?
■
Yes
■
no
■
Yes
■
No
If no, is this person eligible to get
services from the Indian Health
Services, tribal health program,
urban Indian health programs or
through a referral from one of these
programs?
■
Yes
■
no
■
Yes - if yes, please complete
information below:
■
None to report
$_________________
How often? (daily, weekly,
bi-weekly, monthly, yearly, etc.)
_______________________
■
Yes - if yes, please complete
information below:
■
None to report
$_________________
How often? (daily, weekly,
bi-weekly, monthly, yearly, etc.)
_______________________
AI/AN Person 1 AI/AN Person 2
SAWS 2 PLUS (4/15)
APPENDIX C
Appendix C ASSISTANCE WITH COMPLETING THIS APPLICATION
If you want someone to be your authorized representative for the health insurance part of this application, please answer the
questions on this page. If you’re a legally-appointed representative for someone on this application, submit proof with the
application.
1. Name of authorized representative (First name, Middle name, Last name)
3. Apartment or Suite number
6. Zip code
9. I.D. Number (if applicable)
2. Address
5. State
4. City
7. Phone number
( )
8. Organization name (if applicable)
By signing you allow this person to get official information about the health insurance part of this application and act for you on all matters
with Covered California or your County Human Services Agency. As a reminder you can always change your authorized representative
by calling the County or going to the web at www.HealthCare.gov
.
For Certified Application Counselors, Navigators, Agents and Brokers Only.
Complete this section if you are a certified application counselor, navigator, agent, or broker filling out this application for somebody else.
10. Your signature
1. Application start date (mm/dd/yyyy)
2. First name, Middle name, Last name, & Suffix
3. Organization name
4. I.D. number (if applicable)
11. Date
SAWS 2 PLUS (4/15)
APPENDIX D-1
Appendix D EMPLOYMENT HISTORY
If you are applying for cash aid and have two or more adults in the home who are applying for aid, please fill out the
information on this page for each adult. Please tell us about your work history for the past 24 months (two years). If
using the paper application and you need more space, copy this page or use a separate piece of paper.
NAME:
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 1
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 2
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 3
Person1
SAWS 2 PLUS (4/15)
APPENDIX D-2
Appendix D EMPLOYMENT HISTORY CONTINUED
If you are applying for cash aid and have two or more adults in the home who are applying for aid, please fill out the
information on this page for each adult. Please tell us about your work history for the past 24 months (two years). If
using the paper application and you need more space, copy this page or use a separate piece of paper.
NAME:
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 1
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 2
Is this person Native American?
■
Yes
■
No
Name of Tribe:_____________________________________________________
Name and Address of Employer:
Was this your own business (self-employed)?
■
Yes
■
No
How much do you or did you get paid at this job and when? $_________
■
Hourly
■
Daily
■
Weekly
■
Every two weeks
■
Monthly
Did the County help you get this job?
■
Yes
■
No
Dates you worked:
From____________ To______________
Number of hours worked:
■
Daily
■
Weekly
■
Monthly
Reason for leaving this job?
Job 3
Person 2
SAWS 2 PLUS (4/15)
APPENDIX E
Optional for health care: Only answer if someone applying is age 65 or older or is disabled. If you are applying for cash aid, you
MUST answer these questions for each vehicle.
Please provide information for each vehicle that anyone owns, has use of, or has their name on the registration, or even if it is
not running. Vehicle means, car (including truck, van, Sport Utility Vehicle [SUV]), motorcycle, motorized scooters, snowmobile,
recreational vehicle (RV) or motorboat.
Vehicle (1) Vehicle (2)
Vehicle (3)
Owner of vehicle
Name of person who uses this
vehicle
Year/ Make/Model
Vehicle License Number
Is this vehicle a gift, donation,
or family transfer? You may
be asked by the County to
provide proof.
Estimated value of vehicle
(how much your vehicle is
worth)? We call this the Fair
Market Value.
How I found out the
Fair Market Value
How much I owe on the
vehicle
What I used to find the
amount owed on the vehicle
Is this a leased vehicle?
Is this vehicle:
● used as a home?
● used for self-employment,
self-support, or business?
● needed to transport a
disabled household member,
● used to get the household’s
fuel or water?
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Gift
■
Donation
■
Family Transfer
■
Yes
■
No
■
Gift
■
Donation
■
Family Transfer
■
Yes
■
No
■
Gift
■
Donation
■
Family Transfer
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
■
Last Bill
■
Lender statement
■
Estimate
■
Other:__________________
■
Last Bill
■
Lender statement
■
Estimate
■
Other:________________
■
Last Bill
■
Lender statement
■
Estimate
■
Other:__________________
$
■
I don’t know/I need help
finding out the value
$
■
I don’t know/I need help
finding out the value
$
■
I don’t know/I need help
finding out the value
$
■
I don’t know/I need help
finding out the amount owed
$
■
I don’t know/I need help
finding out the amount owed
$
■
I don’t know/I need help
finding out the amount owed
■
For sale ads
■
Car Dealer
■
Kelly blue Book
■
Mechanic
■
Purchase price
■
Other:_________________
■
For sale ads
■
Car Dealer
■
Kelly blue Book
■
Mechanic
■
Purchase price
■
Other:_________________
■
For sale ads
■
Car Dealer
■
Kelly blue Book
■
Mechanic
■
Purchase price
■
Other:_________________
Appendix E VEHICLE INFORMATION AND SELF CERTIFICATION OF EQUITY VALUE
If yes, you may stop
If yes, you may stop
If yes, you may stop
Is this vehicle used by a child
under age 18 to:
●
go to school?
●
work?
●
training?
●
job search?
■
Yes
■
No
■
Yes
■
No
■
Yes
■
No
If yes, you may stop
If yes, you may stop
If yes, you may stop
If yes, check the box that applies,
attach proof from DMV and stop
here. If you do not have proof,
ask the county for help.
If yes, check the box that applies,
attach proof from DMV and stop
here. If you do not have proof,
ask the county for help.
If yes, check the box that applies,
attach proof from DMV and stop
here. If you do not have proof,
ask the county for help.
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APPLICATION FOR CALFRESH , CASH AID , ANDOR (California)

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Completed 22 June 2021

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