M
T. SAN JACINTO COMMUNITY COLLEGE DISTRICT
1499 NORTH STATE STREET SAN JACINTO CA 92583
(951)
487-3295
CARE (COOPERATIVE AGENCIES RESOURCE FOR EDUCATION)
AGENCY CERTIFICATION
TO BE COMPLETED BY STUDENT
State regulations require verification of your TANF/CalWORKs status. The information provided on this form will be used for
determining your eligibility for the CARE program, and will remain confidential. Complete the appropriate information
before submitting this form to the Department of Public Social Services.
I authorize DPSS to provide the information requested below to the CARE program at Mt. San Jacinto Community College
District.
TANF/CalWORKs Case#: ___________________________________________ MSJC ID# _______________________
Applicant Name (PRINT)_______________________________________________ _____________________
Date
I authorize the CalWORKs (GAIN)/DPSS representative to release information requested on this form to Mt. San Jacinto
College EOPS/CARE program.
Applicant Signature___________________________________________________
TO BE COMPLETED BY DPSS REPRESENTATIVE
The student indicated above has applied to Mt. San Jacinto College CARE program. The CARE program assist qualifying
TANF/CalWORKs students with childcare and transportation assistance, book grants and other services as needed.
In order to determine your client’s eligibility for CARE, certification of the following information is critical.
1. Marital status of client: [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed
2. Is this student considered head of a one parent household? [ ] YES [ ] NO
3. Does this student currently receive TANF/CalWORKs cash aid for? [ ] Self [ ] Children [ ] Self/Children
Date began receiving cash aid: ______________________
4. How many dependent children under the age of eighteen years old are in the home? _______________
5. Does the Department of Social Services currently reimburse childcare expenses while the client attends school?
[ ] Yes [ ] NO
6. Current CalWORKs (GAIN) Status and/or activity: _________________________________________________
7. If the student is eligible what support services does GAIN currently provide while the student attends school?
Transportation _____ Books____ Childcare_____ None____
__________________________________________________ _________________________________________
Agency Representative (Type or Print) Title/Official Position
__________________________________________________ _______________________________
Signature Date
__________________________________________________
Telephone Number
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