APPLICATION FOR CALFRESH BENEFITS
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 CalFresh benefits only
. CalFresh is a food assistance program to help
you with the cost of buying food for your household. If you wish to apply for programs other than CalFresh such
as, CalWORKs or Medi-Cal, please ask for an application to apply for other programs. You can also apply for
CalFresh or other programs online by going to http://www.benefitscal.org/
. You can see if you may be eligible by
going to http://www.cdss.ca.gov/foodstamps/PG849.htm.
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) to begin the application process.
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 1 through 5) before
you sign the
application.
You must have an interview with the County to discuss your application. Most interviews are done by phone,
but it can be done in person at the County office or other place arranged with the County. 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. You may be able to get benefits within 3 calendar days, if
you meet one of the Expedited Service criteria:
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 $100 or less; or
Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
cash on hand or in checking or savings accounts; 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.
To help the County see if you can get benefits in three days, please answer questions 1, 6 through 8, 11, and 16,
and give the County proof of your identify (if you have it) with the application.
The County will send you a letter to let you know if your household is approved or denied CalFresh benefits.
Agency Conference
Agency conference is a process that provides the household the right to request a meeting with an eligibility
supervisor (this meeting may be attended by an eligibility worker and an authorized representative) to
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED COVERSHEET PAGE 1 OF 2
informally resolve any dispute as to whether the household meets Expedited Service criteria.
The agency conference shall be scheduled within two working days of the request, unless the household requests
that it be scheduled later or states that they do not wish to have an agency conference.
What do I need for my interview?
To avoid delays, bring proof of the following 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 CalFresh 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.
Proof Needed to Get Benefits
Identification (Driver’s License, State ID card, passport).
Where you live (a rental agreement, current bill with
your address listed).
Social Security Numbers (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 expense 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 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, 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 (e.g., a hallway, a bus station,
a lobby, or similar places).
How do I get/use my CalFresh benefits?
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 use your card.
If your EBT card is lost, stolen, or 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
. Make sure all responsible adults
and your authorized representative also know how to report one of these problems right away
. If you do not
report that another person you do not want to spend your benefits has your PIN and you do not get your PIN
changed, any benefits used 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. For a list of locations
near you that accept EBT please go to: https://www.ebt.ca.gov
or https://www.snapfresh.org.
CalFresh benefits are only
for you and your household members. Keep your benefits safe. Do not give out
your PIN number. Do not
keep your PIN number with your EBT card.
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
Informational Page - Please take and keep for your records.
COVERSHEET PAGE 2 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
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. If
you don’t meet your household’s reporting requirements your case will be closed or your CalFresh 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 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 for CalFresh and get an explanation of the rules.
Ask for help to get proof that is needed.
Be treated with courtesy, consideration, and respect, and not be discriminated against.
Get CalFresh benefits within 3 days if you qualify for Expedited Service.
Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility
determined within 30 days.
Get at least 10 days to give 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 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 CalFresh case. If you
ask for a hearing before an action on your CalFresh case takes place, your CalFresh 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 over paid 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 number – 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 assistance from the County to register to vote.
Report changes that you are not required to report, if it may increase your CalFresh benefits.
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).
Please take and keep for your records
PROGRAM RULES PAGE 1 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
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 benefits 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.
PROGRAM RULES PAGE 2 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Penalties
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 $250,000.00, imprisoned up to 20
years or both
Program Violations
For CalFresh: I understand I may have
committed an intentional program violation
if I do 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, buy, sell, steal or give away CalFresh
benefits or EBT cards, or attempt
to trade, buy,
sell, steal or give away CalFresh benefits or EBT
cards
Try to get dual benefits, for example, apply in two
or more different counties or states at the same
time
Submit false documents for children or adult
household members who are not eligible or who
do not exist
Violate conditions of my probation or parole
Flee after a felony conviction
Purchase (buy) a product with CalFresh benefits
that has a return deposit, intentionally (on
purpose) throw away the contents and return the
container for the deposit amount or attempt
to
return the container for the deposit amount
Buy a product with CalFresh benefits and
intentionally resell it for cash or anything other
than eligible food
Trade CalFresh benefits or attempt to trade
CalFresh benefits for: cash, firearms, non-eligible
goods or 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, selling or
attempting
to trade CalFresh benefits worth more
than $500, or trading or attempting
to trade
CalFresh benefits for firearms, ammunition or
explosives
●Lose CalFresh benefits for 10 years for each
offense
Lose CalFresh benefits permanently
Lose CalFresh benefits for 24 months for the first
offense
Lose CalFresh benefits permanently for the
second offense
Please take and keep for your records
Important Information for Noncitizens
You can apply for and get CalFresh benefits for people who are eligible, even if your family includes others
who are not eligible. For example, immigrant parents may apply for CalFresh benefits 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 CalFresh 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 CalFresh benefits.
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 requested information, the County may
deny your application. You have the 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. 273.2(b)(4) Privacy Act statement. As a County agency, we must notify all
households applying and being recertified for CalFresh benefits of the following:
(i) The collection of this information, including the social security number (SSN) of each household member, is
authorized under the Food Stamp Act of 1977, as amended, 7 U.S.C. 2011-2036. The information will be
used to determine whether your household is eligible or continues to be eligible to participate in the CalFresh
Program. We will verify this information through computer matching programs, including the Income and
Earnings Verification System (IEVS). This information will also be used to monitor compliance with program
regulations and for program management.
(ii) This information may be disclosed to other Federal and State agencies for official examination, and to law
enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
(iii) If a CalFresh claim arises against your household, the information on this application, including all SSNs,
may be referred to Federal and State agencies, as well as private claims collection agencies, for claims
collection action.
(iv) Providing the requested information including the SSN of each household member, is voluntary. However,
failure to provide an SSN will result in the denial of CalFresh benefits to each individual failing to provide an
SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household
members.
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 check your answers using information in state and federal electronic databases from the Internal
Revenue Service (IRS), Social Security Administration, the Department of Homeland Security, and/or a
consumer reporting agency. If the information does not match, the County may ask you to send proof.
Please take and keep for your records
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PROGRAM RULES PAGE 3 OF 6
Use of Social Security Numbers (SSN)
Everyone applying for CalFresh benefits needs to provide a SSN, if they have one, or proof that they have applied
for a SSN (such as a letter from the Social Security Office). The County may deny CalFresh benefits for you or
any member of your household who does not give us a SSN. Some people do not have to give SSN’s to get help
such as, victims of domestic abuse, crime prosecution witnesses, and trafficking victims.
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.
Reporting
Every household that gets CalFresh 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 CalFresh
benefits being lowered or stopped. You can also report if things happen that may increase your benefits, such as
getting less income.
State Hearing
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 a State hearing. If you ask for a hearing before the action happens, you may be able to keep your
CalFresh benefits the same until a decision is made.
Nondiscrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture
(USDA) civil rights regulations and policies, the USDA, its Agencies, offices and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on race, color, national
origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any
program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille,
large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied
for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages
other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD 3027)
found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or contact your
County’s Civil Rights Coordinator, or write a letter addressed to USDA and provide in the letter all of the information
requested in the form or write to California Department of Social Services (CDSS) address below. To request a
copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CDSS
Civil Rights Bureau
P.O.BOX 944243, M.S. 8-16-70
Sacramento, CA 94244-2430
1-866-741-6241 (Toll Free)
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, S.W.
Washington D.C. 20250-9410
(1) mail:
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov
This institution is an equal opportunity provider.
Please take and keep for your records
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PROGRAM RULES PAGE 4 OF 6
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PROGRAM RULES PAGE 5 OF 6
Case File Reviews
Your case may be selected for additional review to ensure that your eligibility was correctly figured. You must
cooperate fully with the County, State, or federal personnel in any investigation or review, including a quality
control review. Failure to cooperate in these reviews could result in loss of your benefits.
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 without a good reason.
EBT Usage
Any benefit taken from your account before you, another household member, or your authorized representative
report the EBT card or PIN has been lost or stolen will not be replaced.
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.
If you do not report that another person you do not want to spend your benefits has your PIN and you do not get
your PIN changed, any benefits used will not be replaced.
Please take and keep for your records
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTES
PROGRAM RULES PAGE 6 OF 6
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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), use page 10 “Additional Writing Space” section and attach additional sheets of
paper if needed to provide the information. Please be sure to identify which question you are writing about in the extra space
or on the additional sheets of paper.
SIGNATURE OF APPLICANT(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
CELL PHONE
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)
CITY
CITY
STATE
STATE
ZIP CODE
ZIP CODE
Is your household’s monthly gross income less than $150 and cash on hand, or in checking and
savings accounts is $100 or less?
Is your household’s combined monthly gross income and cash on hand or in checking and savings accounts
is less than the combined cost of rent/mortgage and utilities?
Is your household a migrant/seasonal farm worker household with liquid resources not exceeding
$100 and either your income stopped or you will not get more than $25 in the next 10 days?
Do you have a disability and need help with applying?
Are you interested in applying for Medi-Cal? If you answer yes the County will use your answers to
find out if you can get Medi-Cal.
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.
My answers to the questions are true and complete to the best of my knowledge.
Any answers I may give for my application process will be true 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) for the CalFresh Program.
I read, or had read to me, the CalFresh Program Rules and Penalties (Program Rules Page 2).
I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for
CalFresh is fraud. 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.
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.
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 1 OF 10
DATE
1. APPLICANT’S INFORMATION
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
EMAIL ADDRESS
CONTACT AUTHORIZATION
Please give the county the best contact information to reach you. This will help in processing your application. By providing your contact
information below, you are authorizing the county to contact you by phone, email or text, or to leave a phone message regarding your
application.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHECK BOX FOR TEXT
(PLEASE CHECK ONE)
3. 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.
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?
(Please Check One)
Yes
No
If yes, complete the following section:
5. OTHER PROGRAMS
Have you or anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Medicaid, Supplemental
Nutrition Assistance Program [CalFresh], General Assistance (GA)/General Relief (GR), etc.)?
(Please Check One)
Yes
No
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
PAGE 2 OF 10
AUTHORIZED REPRESENTATIVE NAME: AUTHORIZED REPRESENTATIVE PHONE NUMBER:
NAME:
ADDRESS: CITY STATE ZIP CODE
PHONE NUMBER:
Do you want to name someone to receive and spend CalFresh benefits for your household? (Please Check One)
Yes
No
If yes, complete the following section:
4. INTERVIEW PREFERENCE
You or another adult member in your household will need to have an interview with the County to discuss your application and to receive
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. In-person interviews will only happen during the County’s normal office hours.
Please check this box if you would prefer an in-person interview.
Please check this box if you need other arrangements due to a disability.
Please check the boxes below for your preferred day and time for an interview:
Day:
Today
Next available day
Any day
Monday
Tuesday
Wednesday
Thursday
Friday
Time:
Early morning
Mid-morning
Afternoon
Late afternoon
Anytime
IF YES, WHO? WHERE (COUNTY/STATE)?
IF YES, WHO? WHERE (COUNTY/STATE)?
If you are of Hispanic or Latino origin, do you consider yourself:
Mexican
Puerto Rican
Cuban
Other___________________________________________
ETHNICITY
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Are you Hispanic or Latino? (Please Check One)
Yes
No
6a. HOUSEHOLD’S INFORMATION
6b. NONCITIZEN INFORMATION - Complete for those listed in question 6a above who are not citizens and are applying for aid.
6c. SPONSORED NONCITIZEN INFORMATION - Complete for those listed in question 6b above who are sponsored noncitizens and
are applying for aid.
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.
Complete the following information for all persons in the home that you buy and prepare food
with, including you. If applying for noncitizens, please complete question 6b and 6c. If
not, go to question 6d.
APPLYING
FOR
BENEFITS
(check Yes
or No)
Name
Date of Entry
into U.S.
(if known)
Give one of the following (if known):
Passport Number,
Alien Registration Number, etc.
Sponsored?
(check Yes or
No) If yes,
complete
question 6c
below:
How is the
person
related to
you?
DATE
OF BIRTH
SELF
GENDER
(M OR F)
NAME
(Last, First, Middle Initial)
Please list the names of anyone who lives with you that does not buy and prepare food with you:
Does anyone listed above have at least 10 years (40 quarters) of work history or military service in the USA?
If yes, who?____________________________________________________________________________
Does anyone listed above have, or have they applied for, or do they plan to apply for a T-Visa,
U-Visa or VAWA status?
If yes, who?___________________________________________________________________________________
U.S.
CITIZEN or
NATIONAL
(check Yes
or No)
If no,
complete
question 6b
below
SOCIAL SECURITY
NUMBER
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
NAME
SPONSOR’S NAME
SPONSOR’S NAME
WHO IS SPONSORED?
WHO IS SPONSORED?
SPONSOR’S PHONE NUMBER
SPONSOR’S PHONE NUMBER
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
DOCUMENT TYPE:_________________________________________________
DOCUMENT NUMBER:______________________________________________
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
NAME
NAME
NAME
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED PAGE 3 OF 10
Social Security number is optional for
members not applying for benefits. You
must answer the questions below for
each person applying for benefits.
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___________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(PLEASE CHECK ONE)
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 4 OF 10
6d. Students
Is anyone who is applying for benefits including you attending a college or vocational school?
(Please Check One)
Yes
No
If yes, please answer this question. If no, skip to the next question.
6e. Is there a foster child living in your home?
Yes
No If yes, who?_________________________________________
Please answer the following questions about the child(ren):
Was this child(ren) placed in your home under a dependence order of the court?
(Please Check One)
Do you want the foster care child(ren) counted in your CalFresh case? (Please Check One)
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.
7. Unearned Income
Do you or anyone you buy and prepare food with get income that does not come from a job (unearned)?
(Please Check One)
Yes
No
If yes, please answer this question. If no, skip to the next question.
Check all types of unearned income that apply from these examples (there may be others not listed here):
Name of Person
Name of School/Training
Expect to
continue?
(Check
Yes or No)
How
much?
From where?
Person getting the money?
Enrolled Status
(check one)
Are They Working?
Average work hours
per week:________
Average work hours
per week:________
Half-time or more
Less than half-time
Number of units:________
Half-time or more
Less than half-time
Number of units:________
$
$
$
$
How often received?
(once, weekly, monthly, or
other)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Social Security
SSI/SSP
Cash aid
CalWORKs/TANF/GA/GR/CAPI
Room and board (from your renter)
Pension
Child/Spousal support
Government/railroad disability or
retirement
Veteran benefits, or Military pension
Financial aid (school grants/loans/
scholarships)
Gift of money
Unemployment Insurance/
State Disability Insurance (SDI)
Worker’s compensation
Lottery/gambling winnings
Help with rent/food/clothing
Insurance or legal settlements
Private disability or retirement
Strike benefits
Other____________________
_________________________
If this income is not expected to continue, please explain:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 5 OF 10
IF YES, WHO?
IF YES, WHO?
DATE OF JOB LOSS, QUIT, OR CHANGE
DATE WENT ON STRIKE
DATE OF LAST PAY
DATE OF LAST PAY
REASON?
REASON?
8. Earned income
Do you or anyone you buy and prepare food with get income from a job (earned income)?
(Please Check One)
Yes
No
If yes, please answer this question. If no, skip to the question 9.
NOTE: If self-employed fill out question 8a.
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, or training, and there may be others not
listed here):
Wages Commissions Tips
Salaries
Work study (students)
8a. Self-Employment
Self-employed household members may deduct actual self-employment expenses or take a standard 40% deduction off of
self-employment income. If you choose actual expenses, you will need to give the County proof of the expenses.
Person working
Employer’s name
and address
Employer’s
phone number
Hourly
rate
Gross
monthly
income
Type of business and name
Date business
started
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:
Has anyone lost a job, changed jobs, quit a job, or reduced work hours within the last 60 days?
(Please Check One)
Yes
No
Is anyone on strike? (Please Check One)
Yes
No
$
$
$
$
$
$
$
$
$
$
$
$
$
Yes
No
Yes
No
Yes
No
Yes
No
Self-employment expenses
(please check one)
40% flat rate
Actual expenses $ ___________
40% flat rate
Actual expenses $ ___________
40% flat rate
Actual expenses $ ___________
40% flat rate
Actual expenses $ ___________
40% flat rate
Actual expenses $ ___________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 6 OF 10
9. Household’s Child/Adult Care Expenses
Do you or anyone you buy and prepare food with pay for the care of a child, disabled adult,
or other dependent so you or the other person can go to work, school, training, or look for a job?
(Please Check One)
Yes
No
If yes, please answer this question. If no, skip to the next question.
Who gets care?
Who gets care?
Who pays child support?
Type of Expenses
Have
Expense?
(Please Check One)
Who pays?
Who helps pay? How much?
How often paid?
Amount
Owed
How often billed?
(weekly/monthly,
other)
Name of child(ren) for whom child support is paid:
Who helps pay?
Amount
paid?
Amount
paid?
Who gives care?
(name and address of provider)
Amount
paid?
How often
paid?
(weekly/monthly,
other)
How often
paid?
(weekly/monthly,
other)
How often paid
(weekly/monthly,
other)
Does anyone help your household pay all or part of your child/adult care costs listed above?
Yes
No If yes, complete below:
$
$
$
$
$
$
$
$
$
$
$
10. Child Support Payments
Are you or anyone you buy and prepare food with 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.
11. Household Expenses
Are you or anyone you buy and prepare food with responsible for any household expenses?
Yes
No If yes, please answer
this question. If no, skip to the next question.
NOTE: Do not 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 and you do not need to fill in the actual amount owed.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Rent or house payment
Property taxes and insurance (if billed separately from
rent or mortgage)
Gas, electric, or other fuel used for heating or cooling,
such as firewood or propane (if billed separately 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?
(Please Check One)
Yes
No If yes, please complete.
Does your household receive, or expect to receive, payment from the Low Income Home Energy Assistance
Program (LIHEAP)?
(Please Check One)
Yes
No
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
12. 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:
(Check all that apply)
Medical or dental care
Hospitalization/outpatient
treatment/nursing care
Prescribed medications
Health and Hospitalization
insurance policy premiums
13. Does anyone who is applying for benefits, including you, get food from any of the following?
(Please Check One)
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
14. Does anyone who is applying for benefits, including you, live at any of the following?
(Please Check One)
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,
number 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: $
IF YES, BY WHO:
HOW MUCH: $
IF YES, BY WHO:
HOW MUCH: $
IF YES, WHO?
IF YES, WHO?
IF YES, WHO?
WHERE?
WHERE?
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)
15. Are you or anyone living with you age 60 or older and unable to buy food and fix meals separately
because of a disability?
(Please Check One)
Yes
No
PAGE 7 OF 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Check all that apply:
If joint account with another person please say so below.
For each box checked above, complete the following information.
Have you or anyone in your household sold, traded, given away, or transferred a resource in the last three months?
(Please Check One)
Yes
No
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
16. Household’s Resources
Do you or anyone you buy and prepare food with 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.
17. Duplicate Benefits
Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP
(federal name for food assistance program, known as CalFresh in California) benefits in any state
after September 22, 1996?
(Please Check One)
If yes, who?_______________________________________________________________
18. Trafficking (trading or selling) of Benefits
Have you or any member of your household ever been convicted of trafficking (trading or selling EBT
cards to others) SNAP benefits of $500 or more after September 22, 1996?
(Please Check One)
If yes, who?_______________________________________________________________
19. 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?
(Please Check One)
If yes, who?_______________________________________________________________
20. 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?
(Please Check One)
If yes, who?_______________________________________________________________
21. 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?
(Please Check One)
If yes, who?_______________________________________________________________
22. 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?
(Please Check One)
If yes, who?_______________________________________________________________
Bank/Credit Union account (Checking)
Bank/Credit Union account (Saving)
Safe Deposit box
Savings Bond(s)
Money Market Account
Mutual Funds
Certificate of Deposit (CD)
Cash on hand
Stocks
Bonds
Other: ____________________
In whose name is the
resource listed?
What type of resource?
How much is
it worth?
Where is the resource?
(include the name of the bank or company
where money is held)
$
$
$
$
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
PAGE 8 OF 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 9 OF 10
Additional Writing Space
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 285 (11/16) REQUIRED FORM - SUBSTITUTES NOT PERMITTED
PAGE 10 OF 10
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 cash on hand, or in checking and
savings accounts $100 or less?
Yes
No
Is the household’s combined gross income and cash on hand or on checking and savings accounts
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 and does not expect to receive more than $25 in next 10 days?
Yes
No
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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