Fillable RECERTIFICATION FOR CALFRESH BENEFITS (California)

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RECERTIFICATION FOR CALFRESH BENEFITS (California)

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CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 1 OF 7
CalFresh Program Rules Page 1 – Please take and keep for your records.
RECERTIFICATION FOR CALFRESH BENEFITS
If you have a disability or need help with the recertification 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 keep getting CalFresh?
You must turn in this recertification application and be interviewed before the end of your certification
period to continue receiving CalFresh. In many counties, you can complete this recertification
application online. To see if you can do this in your county, go to http://www.benefitscal.org/.
NOTE: If you do not currently have health coverage and are interested in the county using information
from your CalFresh application to check your eligibility for Medi-Cal check the box on question 12, page
3 on the recertification application.
How do I complete the recertification application?
Answer all questions on the recertification application, if you can. You must at least provide your name,
address, and signature to begin your recertification process. Read about your rights and your
responsibilities before you sign this application. Turn in the signed application to the County in
person, by mail, by fax, or on-line.
What do I do next?
The County will send you an interview appointment letter to discuss this application. Most interviews
are done by phone, but can also be done in person at the County office or other place if arranged with
the County. If you need other arrangements because of a disability, let the County know. Your worker
can help you complete this application during the interview if you did not fill out all sections or if you
need to make changes.
What happens at the recertification interview?
During the interview, the County will go over the information on the application and will ask questions
to recertify you for CalFresh and determine your benefits. To avoid a delay in recertifying, provide proof
of any changes in circumstance at the time of the interview. Examples are change in income; change
in people buying/eating together, change in housing costs, etc. Keep your interview even if you do not
have the proof. The County may be able to help to get the proof needed to recertify.
What happens if I forget to turn in this recertification application?
You must turn in this application before your certification period ends to recertify for CalFresh. If it is
late, you may have an interruption in your benefits. If you turn in this application more than 30 days
past the end of your certification period, you will have to reapply using the full application.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
What happens after my recertification is approved?
If you reapply timely and get recertified before your certification period ends, you will continue to
receive benefits on your Electronic Benefit Transfer (EBT) card. Continue to use your EBT card and the
same Personal Identification Number (PIN) to buy food. If your EBT card is lost, stolen or destroyed,
call (877) 328-9677 or the County right away
. For a list of locations near you that accept EBT please
go to: https://www.ebt.ca.gov or https://www.snapfresh.org.
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 gave 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 CalFresh benefits may be
lowered or stopped.
● Look for, get, and keep a job or participate in other work-related 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 could result in loss of your benefits.
● Pay back any 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 County 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.
● 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 requested proof to the County 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 any actions taken
on 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.
● 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 assistance from the County to register to vote.
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 2 OF 7
CalFresh Program Rules Page 2 – Please take and keep for your records.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
● 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 may 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).
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 receive. You must pay back any benefits you get that you were
not eligible to receive.
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
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 3 OF 7
CalFresh Program Rules Page 3 – Please take and keep for your records.
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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. Getting food benefits will not
affect you or your family’s immigration status. Immigration information is private and confidential. The
immigration status of noncitizens that 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. However, the
County will need to know their income and resource information to correctly determine your
household’s CalFresh benefits. The County will not contact USCIS about the people who do not
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.
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 4 OF 7
CalFresh Program Rules Page 4 – Please take and keep for your records.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
● 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
Penalties
I may:
● Lose CalFresh benefits for 24 months for the
first offense
● Lose CalFresh benefits permanently for the
second offense
Program Violations
For CalFresh: I understand I may have
committed an intentional program violation
if I do any of the following:
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 5 OF 7
CalFresh Program Rules Page 5 – Please take and keep for your records.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(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.
Use of Social Security Numbers (SSN): Everyone applying for CalFresh benefits 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). 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 gotten. You will
have to pay it back even if the County made an error or if it was not 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: Your household must continue to report the changes the County told you to report. If you
do not report, your benefits may be lowered or stopped. You can also report if things happen that
may increase your benefits, such as receiving less income.
State Hearing: You have the right to a state hearing if you do not agree with any action taken
regarding your recertification for 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.
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.
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 6 OF 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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 So-
cial 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:
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.
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 mandatory work program. If you do not
participate when required by the County, your benefits could be reduced or stopped. You may not be
eligible to CalFresh if you have recently quit a job without a good reason.
EBT Usage: 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.
CalFresh Program Rules Page 6 – Please take and keep for your records.
NOTES
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PROGRAM RULES PAGE 7 OF 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
To keep your benefits coming on time without a break, please fill out, sign, date, and return this form to the county and provide proof of
your circumstances before the end of your certification period. We need the information before or at your interview to finish the
recertification. We need at least
your name, signature, address, and dated form to begin the CalFresh recertification.
Case Name: _____________________________________ Case Number: _____________________________________
4. If you have moved or have new/changed housing costs in the last six months, please fill out the section below:
Your rent or mortgage per month now? $_____________
If paid separately, your property taxes and home insurance per month now? $_______________
4a. Do you have utility costs that are not included in your housing costs? If so, check which ones:
Phone Trash Water Electric/Gas Other heating or cooling costs
RECERTIFICATION APPLICATION - CALFRESH ONLY HOUSEHOLDS
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PAGE 1 OF 4
■
■
■ ■
■ ■
■ ■
■ ■
■ ■
Yes No
Yes No
Yes No
In Out / /
In Out / /
In Out / /
/ /
/ /
/ /
Date of Move
(mm/dd/yy)
Name
(First, Middle, Last)
Date Of Birth
Relationship To
You
Regularly Purchase And
Prepare Food Together?
3. Have there been any changes to your address in the last six months? (Please Check One) Yes No If yes, complete the section below:
New Address: _________________________________________________________________Date Moved: ____________________
Mailing Address (if different from above) ___________________________________________________________________________
2. 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:
NAME PHONE NUMBER
AUTHORIZED REPRESENTATIVE NAME AUTHORIZED REPRESENTATIVE PHONE NUMBER
ADDRESS CITY STATE ZIP CODE
1. Has anyone moved into or out of your home (including newborns) in the last six months? (Please Check One) Yes No
(If yes, complete the section below)
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:
MAILING ADDRESS CITY STATE ZIP CODE
HOME PHONE CELL PHONE CHECK BOX FOR TEXT
WORK/ALTERNATE/MESSAGE PHONE 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, text,or to leave a phone message regarding your application.
■
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
8a. Will there be any changes to this income in the next six months? (Please Check One) Yes No
If yes, explain here: ___________________________________________________________________________________________
One-time or ongoing payment How much/How oftenSource of IncomeName
Case Name: _____________________________________ Case Number: _____________________________________
Name of Person
Name of School/Training
Enrolled Status
(
a
check one)
Is this person Working?
Half-time or more
Less than half-time
Number of units:________
NO
YES, Average work hours
per week:________
7. Do you or anyone you buy and prepare food with get income from a job (earned)? (Please Check One)
Yes No
If yes, complete the section below and attach proof. List each job for each person who works. If you need more space, attach a separate
piece of paper and identify which question you are writing about. Examples include babysitting, salary, self-employment, sick pay, tips, etc.
Job #1 Job #2 Job #3
Name of Person who gets
income:
Employer Name:
Self-employed, chec
k
How often paid:
Weekly Biweekly Other
Monthly Twice Monthly
Monthly Gross Amount of
Income:
$
Hours worked per month:
Will this income continue?
Yes No
Self-employed, check
Weekly Biweekly Other
Monthly Twice Monthly
$
Yes No
Self-employed, check
Weekly Biweekly Other
Monthly Twice Monthly
$
Yes No
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PAGE 2 OF 4
Half-time or more
Less than half-time
Number of units:________
NO
YES, Average work hours
per week:________
7a. Will there be any changes to anyone’s job or income in the next six months? (Please Check One)
Yes
No
Examples: Stopping, starting, increase or decrease of income, change in hours, quitting a job, going on strike, change in how often
anyone is paid.
If yes, explain here and attach any proof: _________________________________________________________________________
___________________________________________________________________________________________________________
6. Students: Is anyone who is applying for benefits including you attending a college or vocational school? (Please Check One)
Yes No If yes, please provide the information below. If no, skip to the next question.
5. Are you homeless? Yes No If yes, do you pay shelter costs? (Please Check One) Yes No
8. Do you or anyone you buy or prepare food with get income that does not come from a job (unearned)?
(Please Check One)
Yes No
If yes, complete the section below and attach proof. Examples include: Social Security, Unemployment Compensation, Veteran’s Benefits,
State Disability Insurance (SDI), Child/Spousal Support, Worker’s Compensation, Loan/Gifts, Earned/Unearned Housing, Utilities, Food, etc.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
9. Medical Costs: Did anyone who gets CalFresh and is 60 years old or older, or disabled, have an increase or begin paying
medical costs? (Please Check One) Yes No
(If yes, complete the section below and attach proof if this is a new expense or if change is more than $25.)
Who had the cost? __________________________________ Type of cost _________________
Amount paid? ___________________ How often? ________________________
10. Child Support: Did anyone who gets CalFresh have to pay child support? (Please Check One)
Yes No
(If yes, complete the section below and attach proof, if this is a new child support obligation or a change in the legal obligation to pay
child support or an increase in the amount of child support paid.)
Name(s) of children __________________________________________________________________________________________
What is the current amount they have to pay? $ _______________ Who paid support? ___________________________________
11. Dependent or Child Care: 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? (Please Check One)
Yes No
(If yes, please only list the amount you or anyone in your household pays out of pocket. Attach proof if provider or the out-of-pocket
amount has changed.)
Amount: $__________________ Who paid: ____________________________List dependent/child: ___________________________
12. Are you interested in applying for Medi-Cal? (Please Check One)
Yes No
If you answer “yes”, the County will use your information to find out if you can get Medi-Cal.
13. 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)
Yes No
If yes, who? _________________________________________________________________________________________________
14. 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)
Yes No
If yes, who? _________________________________________________________________________________________________
15. 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)
Yes No If yes, who? ________________________________________________________________________
16. 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)
Yes No
If yes, who? _________________________________________________________________________________________________
17. 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)
Yes No
If yes, who? _________________________________________________________________________________________________
18. 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)
Yes No
If yes, who? _________________________________________________________________________________________________
Case Name: _____________________________________ Case Number: _____________________________________
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PAGE 3 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CERTIFICATION
Please read carefully, sign, and date. By signing this form:
I understand that by signing this recertification application under penalty of perjury (making false statements), that:
● I read, or had read to me, the information in this recertification application and my answers to the questions in this recertification
application.
● My answers to the questions are true and complete to the best of my knowledge.
● Any answers I may give for my recertification process will be true and complete to the best of my knowledge.
● I read or had read to me the Rights and Responsibilities (Program Rules Page 2) for the CalFresh Program and the CalFresh
Program Rules and Penalties (Program Rules Pages 3 through 4).
● 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.
TO CONTINUE RECEIVING BENEFITS, YOU MUST SIGN AND DATE THIS APPLICATION AND BE
INTERVIEWED BEFORE THE LAST DAY OF YOUR CERTIFICATION PERIOD.
WHO MUST SIGN BELOW: Adult household member/Authorized Representative/Guardian
Signature or Mark of Applicant Date Contact email/phone
Case Name: __________________________________________ Case Number: _________________________________________
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED PAGE 4 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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RECERTIFICATION FOR CALFRESH BENEFITS (California)

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Completed 28 July 2020

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