Fillable STATEMENT OF FACTS FOR AN ADDITIONAL PERSON 2 (California)

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STATEMENT OF FACTS FOR AN ADDITIONAL PERSON 2 (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS FOR AN ADDITIONAL PERSON
(Supplemental Application for CalFresh and Request for Cash Aid)
INSTRUCTIONS: Fill out this form to tell us about a new person in the home. If you need more space to
answer the questions, attach another sheet of paper. Fill in the answers for all the questions about the
benefits you are asking for. The "CA" for cash aid and "CF" for CalFresh listed to the left side of each
question tell you which questions are for which program.
If you get cash aid, and you want aid for the new person, this form must be filled out by either the adult
caretaker relative who is now getting cash aid or the new person, unless the new person is a child.
For CalFresh households, which do not get cash aid or do not want cash aid for the new person, this form
may be completed by a household member, an authorized representative or the new person.
PLEASE PRINT IN INK
CA
CF
1 Name of Person Completing Form (First, Middle, Last)
CA
CF
2 List new person in the home, including a newborn.
NAME (First Middle Last)
CITIZEN/NONCITIZEN STATUS ()
U.S. Citizen/National
Noncitizen: Sponsored YES NO
SOCIAL SECURITY NUMBER
- -
BIRTHDATE
- -
PREGNANT
YES NO
IS HE/SHE A PARENT?
YES NO
BIRTHPLACE ( City/State/Country)
SEX ()
M F
MARITAL STATUS
Married
Never Married Separated
Divorced Common Law Widowed
BLIND/DEAF/DISABLED
YES NO
SCHOOL STATUS
()
Has a High School Diploma
Has a GED
Currently Attending School
Not Attending School (Explain):
RELATED TO APPLICANT/CARETAKER/HEAD OF HOUSEHOLD?
YES NO
If “YES”, explain relationship:
ANY OTHER NAME USED: (Maiden, adoptive, etc.)
TYPE OF AID REQUESTED () Cash Aid CalFresh
CA
CF
3
Has he/she applied for or received benefits in the past, such as: cash aid,
CalFresh, homeless assistance, Medi-Cal, Refugee Cash Assistance?
YES NO
If "YES", explain:
WHEN WHERE (County, State, or Country) TYPE OF BENEFIT
CA 4 Is he/she a child under age 19? If “YES”, complete below: YES NO
PARENT OR CARETAKER
RELATIVE’S NAME
() Lives in Home
Yes
No
OTHER PARENT’S NAME
() Lives in Home
Yes
No
Reason Other Parent
Does Not Live
in the Home
Child Needs Aid
Due to Parent’s
(Check all boxes which apply)
Absence
Unemployment
Incapacity
Death
CA
CF
5
Has he/she been in the U.S. military service or the spouse, parent or child
of a person who has been in the military service?
YES NO
If “YES”, explain:
LIST NAME, BRANCH OF SERVICE, ETC. HONORABLE DISCHARGE
YES NO
CA 6 Does he/she presently live in California and intend to continue living here? YES NO
If “NO”, explain:
____________
______
________
COUNTY USE ONLY
CASE NAME
CASE NUMBER
WORKER NAME
WORKER NUMBER
DATE RECEIVED
VERIFIED: YES NO
SSN
CF ID
Blind/Deaf/Disabled
Residency
DFA 285-C Comp.
CW 25 Completed
QR 25 A Completed
Referred to WTW
Citizen
Eligible Non-citizen
Sponsored
SAVE
Date of Entry to U.S.
Excluded HH Member Code
Work/Training/WTW Code
VERIFIED:
Deprivation
YES NO
CW 5
YES
NO
Date Initiated ____________
CW 8 (11/14) RECOMMENDED FORM
Page 1 of 6
CA
CF
7 Is he/she a foster child living in the home?
YES
NO
A. Was the child placed in your home under a dependency order from
the court?
YES
NO
B. Do you want the foster child and foster care income counted on the
CalFresh case?
YES
NO
C. Is the child enrolled in a health care plan?
YES
NO
CA
CF
8 A. Is he/she 16 or older and enrolled in school, college, or a training
program? If “YES”, complete below:
YES
NO
NAME OF SCHOOL/COLLEGE/TRAINING
PROGRAM
IF ENROLLED, CHECK ( ) STATUS
Full time
Half time
Other (specify):
UNITS/HOURS
PER WEEK
EXPECTED DATE
OF GRADUATION
WORKING?
YES
NO
CA
CF
B. Complete below if he/she is enrolled in college or attending a similar educational institution.
TERM
Semester
Year
Quarte
r
TUITION/FEES PER TERM
$
BOOKS, EQUIPMENT, ETC., PER TERM
$
ROUND TRIP PER DAY TO
SCHOOL/CHILD CARE (MILES)
DAYS ATTENDING PER WEEK TRANSPORTATION USED
TRANSPORTATION COST PER WEEK
$
AMOUNT PAID BY CARPOOL MEMBERS
$
PUBLIC TRANSPORTATION (BUS, ETC.) PER DAY
$
CA
CF
9 Has he/she had cash aid or CalFresh stopped for a period of time or
forever due to: non-cooperation during a quality control review, work or
training sanctions, or due to welfare fraud or an Intentional Program Violation?
YES
NO
If “YES”, complete below:
WHY WHEN WHAT COUNTY/STATE
CA
CF
10 Is any member of the 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? If “YES”, give name of the person:
YES
NO
CA
CF
11 Has any member of the household been found by a court of law to be
in violation of probation or parole? If “YES”, give name of the person:
YES
NO
CF 12 Does he/she regularly buy food and fix meals separately from others
in the home?
YES
NO
CF 13 Is he/she age 60 or older and unable to buy food and fix meals
separately because of a disability?
YES
NO
CF
14
Does he/she pay you for meals and/or a room?
YES
NO
CHECK ( )
Meals
Room
Both
HOW MUCH
$
HOW OFTEN NO. OF MEALS
PER DAY
CF 15 Does he/she get food from any of the following programs?
YES
NO
Communal dining facility for the elderly or disabled
Food distribution program operated by a Native American reservation
Other food program
If “YES”, complete below:
NAME OF PROGRAM
COUNTY USE ONLY
7A:
Request dependency order
7B: CA and FC Elig/CR Chooses:
Child:
CA
FC
CR:
CA
None
Kin-GAP
7C:
Medi-Cal
Fee for Service
VERIFIED:
School Enrollment
Yes
No
CF Eligible Student
Yes
No
VERIFIED:
Expenses
Yes
No
Financial Aid
Yes
No
Separate household eligible
Yes
No
Separate household eligible
Yes
No
Household Elects
BOARDER HH MEMBER ROOMER
CW 8 (11/14) RECOMMENDED FORM
Page 2 of 6
CA
CF
16
Is he/she working now or expecting to be working in the future? YES NO
If “YES”, complete below. Attach paystubs or other proof of earnings. If job
hasn’t started what is the anticipated start date?
(Note: If self-employed, list business expenses on a separate sheet of paper and attach it to this form).
EMPLOYER NAME SELF EMPLOYED
YES NO
OCCUPATION DAYS/HOURS WORKED PER MONTH
PAY DATE(S)
WAGES BEFORE DEDUCTIONS
$ per
TIPS OR COMMISSIONS
YES Amount $ NO
Will this income continue? YES NO If “NO”, explain any changes here:
CA
CF
17
A. Does he/she pay someone to care for a child, disabled adult or other
dependent so he/she can go
to work or training or look for a job?
YES NO
If “YES”, complete below:
NAME OF PERSON WHO RECEIVES CARE NAME OF PERSON WHO GIVES CARE MONTHLY AMOUNT PAID
$
NAME OF PERSON WHO RECEIVES CARE NAME OF PERSON WHO GIVES CARE MONTHLY AMOUNT PAID
$
CA
CF
B. Does he/she get child care costs paid for them?
Include costs paid by a relative or friend, Department of Education, Student Aid,
Block Grant, Cal-Learn,TCC, NET, WTW, SCC, CAAP, etc.
YES NO
If “YES”, complete below:
NAME OF CHILD WHO PAYS MONTHLY AMOUNT PAID
$
NAME OF CHILD WHO PAYS MONTHLY AMOUNT PAID
$
CA
CF
18
Has he/she stopped or refused work or training in the last 60 days? YES NO
If “YES”, complete below:
NAME AND ADDRESS OF EMPLOYER/TRAINING PROGRAM
Did this person get or expect to get wages or benefits this month?
YES NO
If “YES”, complete below.
LAST PAYCHECK RECEIVED (DATE) AMOUNT BEFORE DEDUCTIONS
$
EXPECTED CHECK (DATE) AMOUNT BEFORE DEDUCTIONS
$
NUMBER OF HOURS OF WORK/TRAINING
Last Month
This Month
LAST DAY OF WORK/TRAINING TIPS OR COMMISSIONS
YES Amount $ NO
REASON FOR LEAVING JOB/TRAINING
CA
CF
19
Is he/she on strike? YES NO
If “YES”, complete below:
NAME AND ADDRESS OF EMPLOYER/TRAINING PROGRAM NAME OF UNION
DATE WENT ON STRIKE
GROSS MONTHLY INCOME EARNED FROM THIS JOB BEFORE THE STRIKE
$
CF 20 Does he/she pay child or spousal support? YES NO
If “YES”, complete below:
NAME OF CHILD OR SPOUSE AMOUNT PER MONTH
$
COURT ORDERED
YES NO
CA
CF
21
Has he/she applied for or received any other benefits in the last 12 months,
such as: Social Security
,
Unemployment/Disability Insurance, Cash Aid,
Child/Spousal Support, Veterans Benefits, Free Housing, Free Utilities, etc.?
YES NO
If “YES”, complete below:
TYPE
BENEFIT AMOUNT
$
DATE
APPLIED
WHERE
(COUNTY/STATE)
DATE LAST
RECEIVED
HOW OFTEN
(Weekly, Monthly,Etc.)
DATE EXPECTED
TO START AND STOP
START:
STOP:
Will this income continue? YES NO If “NO”, explain any changes here:
COUNTY USE ONLY
if Exempt
CA
CF Adult
CF Child
CF S/E Farmer Yes No
Verification(s) on file: Yes No
Child Care Informing
Given to Client:
Trustline
Informing
(CCP 2)
Yes No
Health & Safety
Certification
(CCP 5)
Yes No
Dependent Care Eligible
CA
Yes No
CF
Yes No
YES NO
Emp. Statement
Good Cause Determ
Voluntary Quit
CA: 30 days
CF: 60 days
Striker Regs Apply
CA
Yes No
CF
Yes No
Court Order on File Yes No
Amount Ordered
$
if Exempt
CA CF
____________________
()
_____________
_____________
(
)
CW 8 (11/14) RECOMMENDED FORM
Page 3 of 6
COUNTY USE ONLY
CA
CF
22 Does he/she own or is he/she buying any real estate, such as land
and/or buildings anywhere, including outside the U.S.?
YES
NO
If “YES”, complete below:
TYPE (LAND, HOUSE,
APARTMENT, ETC.)
USE (HOME,
RENTAL, ETC.)
ADDRESS OR LOCATION ESTIMATED
VALUE
$
AMOUNT OWED
$
CA
CF
23 A. Does he/she have any of the following resources?
YES
NO
If “YES” check
()
each item and explain below:
RESOURCE YES NO
Checks or Money
(at home or elsewhere)
Checking/Savings/Credit Union
Account
Notes, Mortgages, Trust Deeds,
Sales Contracts
RESOURCE YES NO
Trust Funds
Stocks, Bonds, Certificates,
IRAs, Retirement Funds
Other (list below)
TYPE OF RESOURCE OWNER ACCOUNT/POLICY NO. NAME AND ADDRESS OF BANK, ETC. CURRENT VALUE
$
$
CA
CF
B. Does he/she get income from any of these resources, such as
interest, dividends, etc.?
YES
NO
If “YES,” list each item and explain below:
SOURCE OF MONEY HOW MUCH
$
$
HOW OFTEN
CA
CF
24 Does he/she own, lease, or use any motor vehicles, such as a
YES
NO
car, truck, boat, trailer, van, mobile home, off-road vehicle (ATVs),
motorcycle, seadoos, jetskis, etc.?
If “YES”, complete below:
NAME OF OWNER
IF LEASED CHECK () HOW USED
YEAR, MAKE,
MODEL
LICENSE NUMBER &
STATE OF REGISTRATION
LICENSED
()
ESTIMATED
VALUE
BALANCE
OWED
Leased
Yes
No
$ $
CA
CF
25
Does he/she own or use personal property which cost at least $100 for
each item or is now worth at least $100 each, such as: jewelry,
equipment, instruments, livestock, etc.? Do not list clothing,
wedding rings, rugs, furniture, appliances, or other household furnishings.
YES
NO
If “YES”, complete below:
OWNER NAME OF ITEM DATE BOUGHT
PURCHASE PRICE OR
CURRENT VALUE BALANCE OWED
$ $
$ $
CA
CF
26
Has he/she sold, transferred or given away any real or personal property
within the last 2 years for cash aid and within the last 3 months for CalFresh?
YES
NO
If “YES”, explain below:
CA
27
Does he/she have any of the following insurance coverage: life, burial,
disability or mortgage?
YES
NO
If “YES”, complete below:
NAME OF INSURANCE COMPANY POLICY NUMBER PREMIUM PAID BY
(NAME)
AMOUNT PAID
$
CA
CF
28 Does he/she have health or hospitalization insurance, including insurance
paid for by an employer or absent parent, such as: Blue Cross, Kaiser,
CHAMPUS, Medicare, etc.?
YES
NO
If “YES”, complete below:
NAME OF INSURANCE COMPANY EXPIRATION DATE PREMIUM AMOUNT HOW OFTEN PAID
$
Home Exempt
Yes
No
Other Real Property
Market Value
$__________
Amount Owed $__________
Net Value $__________
Lien Applicable
Yes
No
() if Exempt
CA CF
()
If
Exempt
Leased
Vehicle
Valuation
Exempt
Leased
Owned Jointly
Owned Separately
Net Market Value
$ _____________
Closed Bank Accounts:
CalFresh in
last 3 months
Total CSV
(1) ____________
(2) ____________
Total Countable Property:
Items 22-27
CA
$
_____________
CF
$
_____________
Health Care Options
Explanation Given
Referral __________
NA ______________
DHS 6155
DFA 285-C
Medicare Gross Premium
$
_______________
CW 8 (11/14) RECOMMENDED FORM
Page 4 of 6
CA
29 Did he/she get medical/ pregnancy treatment this month or in the three
months before this month?
YES
NO
If “YES”, complete below:
NAME OF PERSON RECEIVING CARE MONTHS OF CARE
WAS PAYMENT MADE
FOR TREATMENT?
WANT MEDI-CAL
FOR THOSE MONTHS?
YES NO YES NO
CA 30 Does he/she have any health insurance available from a parent,
employer or absent parent, which has not been applied for?
YES
NO
If “YES”, complete below:
NAME OF INSURANCE COMPANY PREMIUM AMOUNT HOW OFTEN PAID
$
$
CA
CF
31 Does he/she have a disability caused by injury or accident which
makes it difficult for them to work or take care of their needs?
YES
NO
If “YES”, complete below:
TYPE OF PROBLEM
DATE PROBLEM
STARTED
EXPECTED DATE
OF RECOVERY
CA
CF
32 A. Does he/she have a medical condition(s) or situation(s) that requires any of the following?
Check
() each item YES or NO:
YES NO
Special diet--prescribed by a doctor
Special transportation need
Special telephone or other equipment
Housework (no one in the home can do it)
YES NO
Very high use of utilities
Special laundry service
Other (specify):
If ‘YES”, explain:
CA
CF
B.
Does he/she get In-Home Supportive Services (IHSS)?
YES
NO
If “
YES”, how much does he/she pay each month? $______________
CA
33 The following services are available. Answers to these questions for yourself or any-
one in the family will not affect your eligibility.
Check () each item YES or NO.
A. Regular check-ups to help protect your family’s health are available
upon request through the Child Health and Disability Prevention
program (CHDP) for eligible members of your family under age 21
.
YES NO
•
Do you want more information about CHDP Services? . . . . . . . . . . . . . . . . .
•
Do you want CHDP medical services?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
Do you want CHDP dental services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
Do you need help making appointments or with transportation
to CHDP Services?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. If anyone in the family is pregnant, you can get help finding a doctor, getting
healthy foods, and other help. Do you want to talk to someone about this help?
C. Is anyone in the family breastfeeding a child?
If “YES”, was the birth within the last 12 months?
If you checked “YES” to 33 B or C, you may be eligible for services
provided by the Women, Infants and Children (WIC) Special Supplemental
Food Program.
D. Do you or any family member want free or low-cost family planning services ?
If “YES”, call your health care plan or regular doctor.
Or, for facts and the location of confidential family planning clinics,
call toll-free 1-800-942-1054.
. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
COUNTY USE ONLY
Retro Medi-Cal
Requested
Yes
No
Approved
Yes
No
DHS 6155
VERIFIED:
Higher/Lower
MAP
Yes
No
Special Need
Yes
No
DFA 285-C
CA
Special Need
Yes
No
Amount $___________
VERIFIED:
CA
Yes
No
CF
Yes
No
DFA 285-C
DFA 285-C
CHDP Brochure and
Explanation Given
Date: _____________
Referral
Pregnant
Parent or Guardian of
child under 5
Breastfeeding
Postpartum
WIC referral
Family Planning
Information Given
Referred Date _________
CW 8 (11/14) RECOMMENDED FORM
Page 5 of 6
CERTIFICATION
I understand that:
• Any facts I gave, including benefit and income facts, will be
matched with local, state and federal records, such as
employers, the Social Security Administration, tax, welfare and
unemployment agencies, school attendance, etc. And for cash
aid and CalFresh, records will be matched with law
enforcement agencies for arrest warrants.
• All facts I gave, including benefit and income facts, may be
reviewed and checked out by county, state, and federal
personnel, and if I gave wrong facts, my cash aid, CalFresh,
and Medi-Cal may be denied or stopped.
• My case may be picked for reviews to ensure that my eligibility
was correctly figured and I must cooperate fully with county,
state or federal personnel in any investigation or review,
including a quality control review.
• The county will send facts to the U.S. Citizenship and
Immigration Services (USCIS) to verify immigration status and
the facts the county gets from USCIS may affect my eligibility
for cash aid, CalFresh and full Medi-Cal. But if I am applying
for Medi-Cal Only, AND if I am not (a) a lawful permanent
resident alien (LPR), (b) an amnesty alien with a valid and
current I-688, or (c) an alien permanently residing in the United
States under color of law (PRUCOL), the county will not send
facts to the USCIS.
• I must apply for and keep any available health coverage if no
cost is involved; if I do not my Medi-Cal will be denied or
stopped.
• I or other family members will be required to repay any cash aid
I should not have received.
• The CalFresh household, any adult member of a CalFresh
household (even if he/she moves out), the sponsor of a
noncitizen household member or the authorized representative
of residents in an eligible institution may be required to repay
any benefits the household should not have received.
• Any member of my household who is 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 or has been
found by a court of law to be in violation of their probation or
parole cannot get cash aid or CalFresh.
• For cash aid, the county will require that I and certain
household members be fingerprint and photo imaged. Benefits
may be denied or stopped if we do not cooperate.
I also understand that:
I will get disqualification and/or welfare fraud penalties if on purpose I
give wrong facts or fail to report all facts or situations that affect my
eligibility or benefits for cash aid, CalFresh, and Medi-Cal.
For cash aid:
• If I on purpose do not follow cash aid rules, I may be fined up to
$10,000 and/or sent to jail/prison for 3 years. And my cash aid
can be stopped:
- For not reporting all facts or for giving wrong facts:
6 months for the first offense, 12 months for the second, or
forever for the third; and for Refugee Cash Assistance,
3 months for the first and 6 months for any later offense.
- For submitting one or more applications to get aid in more
than one case at the same time: 2 years for the first
conviction, 4 years for the second, or forever for the third.
- For conviction of felony thefts to get aid: 2 years for theft of
amounts under $2,000; 5 years for amounts of $2,000
through $4,999.99; and forever for amounts of $5,000 or
more.
- For giving the county false proof of residency in order to get
aid in two or more counties or states at the same time;
giving the county false proof for an ineligible child or a child
that does not exist; getting more than $10,000 in cash
benefits through fraud; getting a third conviction for fraud in
a court of law or an administrative hearing: forever.
For CalFresh:
• If on purpose I do not follow CalFresh rules, my CalFresh
benefits will be stopped for 12 months for the first violation,
24 months for the second, and forever for the third. And I may
be fined up to $250,000 and/or sent to jail/prison for 20 years.
• If I am found guilty in any court of law because:
- I traded or sold CalFresh benefits for firearms, ammunition,
or explosives, my CalFresh can be stopped forever for the
first violation.
- I traded or sold CalFresh benefits for controlled
substances, my CalFresh can be stopped for 24 months for
the first violation and forever for the second.
- I traded or sold CalFresh benefits that were worth $500 or
more, my CalFresh can be stopped forever.
- I filed two or more applications for CalFresh at the same
time and gave the county false identity or residence
information, my CalFresh can be stopped for 10 years.
I declare under penalty of perjury under the laws of the United States of America and the State of California that the
information in this statement of facts is true, correct, and complete.
SIGNATURE (PARENT OR CARETAKER RELATIVE, MEDI-CAL APPLICANT, ADULT CALFRESH HOUSEHOLD MEMBER OR CALFRESH AUTHORIZED REPRESENTATIVE)
SIGNATURE (OTHER PARENT LIVING IN THE HOME, IF APPLYING FOR CASH AID) DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER OR PERSON
ACTING FOR APPLICANT/BENEFICIARY
DATE
CW 8 (11/14) RECOMMENDED FORM
Page 6 of 6
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STATEMENT OF FACTS FOR AN ADDITIONAL PERSON 2 (California)

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