San Diego City College
1313 Park Blvd, Room A-354 ~ San Diego CA 92101-4787
(619) 388-3209 Office (619) 388-3163 Fax
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CSID#: ____________________________ Case#: _______________________________
Name:
__________________________________________________________________________________
LAST FIRST M.I.
Address: __________________________________________________________________________________________________
STREET CITY STATE ZIP
Email Address: _____________________________________ Primary Phone#: ___________________
Marital Status:
Married Single Divorced Separated Widowed
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Yes No Have you applied to the San Diego City College EOPS Program?
Yes No Do you (or your children) currently receive CalWORKs Cash Aid?
Yes No Do you have at least one child under 18 years old?
Yes No Are you designated by the County HHSA as Single Head of Household?
Yes No Are you at least 18 years old?
Yes No Did you participate in the CARE Program during: Fall 2019 Spring 2020
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Include yourself, spouse, or father of child/children (if applicable), dependent children and other dependents (if they will
receive more than half of their support from you).
CERTIFICATION
By typing my name below, I certify under penalty of perjury, that all information on this form is true and complete to the best of my
knowledge. I also understand that false statements or failure to provide proof when requested may result in denial, modification
and/or cancellation of program participation and repayment of any financial assistance received.
______
______________________________________ _____________________________________
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EOPS Eligible: Yes No Date: _________ Staff Initials: _______
CARE Eligible: Yes No Date: __________ Staff Initials: _______
Com
ments: __________________________________________________________________
