CalFresh Outreach
Food Bank of Contra Costa and Solano
CalFresh Intake Form
Full Name: _______________________________________ Phone: (___) ______________
Mailing Address: ______________________________ City: _____________ Zip: _________
Preferred language (if not English): ____________________
Enter preferred contact time. County will try to accommodate.
(Monday- Friday 8am-5pm): ___________________________________
An in person interview
A phone interview
I would like to receive follow-up messages about my application by:
Text
E-mail (if yes, email address):_____________________________________________
Others you share meals with
(Must include spouse)
Check all that apply
Household Size: ____
Name
Gender
(M/F)
Date of
Birth
(REQUIRED
FOR EACH
PERSON)
Citizen
Permanent Resident
Undocumented
SSI Benefits
60+
Disabled
College Student
Social Security
Number
(leave blank if unsure but will
need to provide later at
interview)
SELF
Application Date: ___________ Location: Los Medanos College Taken By: ____________________
Type: Los Medanos College Food Pantry
LMC Staff- Do not fill
CalFresh Outreach
Food Bank of Contra Costa and Solano
Income for the last month before taxes
(or average monthly income)
Include child support, alimony, unemployment, social security, retirement, disability, regular
assistance from family, etc. (exclude SSI)
Monthly housing costs
Include rent, mortgage, property taxes, homeowners insurance, homeless shelter expenses
Monthly utility costs
Include gas/electric, water, sewage, garbage, cell phone, land line phone
Additional information if applicable:
Monthly childcare payments: ______________
M
onthly child support payments (court ordered only):
______________
Student
Exemption Info (Check any that apply to you):
I work on average 20 hours per week
Have been approved for State or Federal Work Study
Approved for Extended Opportunity Program & Services (EOP/EOPS)
Approved for College Disabled Students Programs and Services (DSPS)
Approved for Cooperative Agencies Resources for Education (CARE) Program
Enrolled in the Puente Project
Enrolled in the Mathematics, Engineering, Science Achievement (MESA) Program
Part of a Foster Youth Program (START)
Receive Cal Grant A
Other _________________________________
Demographic Data
(please check all that apply for anyone in the household, does not affect eligibility)
Senior (60+) Working Children (<18) Latino
Homeless Disabled
None of the above
Veteran
To Complete Later: Oasis Upload ROI Email WIC Referral BCW#: _______________
Income and Expenses: y
ou may be required to provide documentation to the County for further consideration
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