Cal Fresh Application

Cal Fresh Application

Applicant Information

Date of Birth:    Social Security Number (last 4 or full):

Primary Phone:    Alternate Phone:

Preferred Language:    Interpreter Needed:

Household Composition

List everyone who lives with you. Include yourself and all persons you buy and prepare food with or who are members of your household.

Relationship to Applicant:    Date of Birth:    SSN (if any):

Relationship to Applicant:    Date of Birth:    SSN (if any):

Relationship to Applicant:    Date of Birth:    SSN (if any):

Income and Resources

Report all income for each household member. Include earned (wages, self-employment) and unearned (benefits, pensions) income.

Person Receiving:    Gross Amount (monthly):    Frequency:

Person Receiving:    Gross Amount (monthly):    Frequency:

Expenses

Immigration and Noncitizen Status

Citizenship / Immigration Status (check one):   Citizen    Noncitizen eligible    Noncitizen ineligible

Additional Questions

Are you requesting expedited service due to immediate need for food?

Do you want benefits loaded to an EBT card?

Certification and Authorization

I certify under penalty of perjury under the laws of the State of California that the information provided in this application is true, correct, and complete to the best of my knowledge. I understand that the county will verify the information contained in this application with employers, financial institutions, landlords, other public assistance programs, and any other source necessary to determine eligibility and benefit levels.

I understand that willful misrepresentation or failure to report information may result in denial or termination of benefits, civil liability for the value of benefits received, criminal prosecution, and/or other penalties as provided by law. I authorize the release of information necessary to establish and verify eligibility for Cal Fresh benefits, including information concerning immigration status where applicable.

I understand my right to a fair hearing if I disagree with any decision about my eligibility or benefits and that I must request a hearing within the timeframes specified by the county. I also understand that I may designate an authorized representative to act on my behalf and that documentation may be required to verify identity and authority.

Consent to Electronic Communication: I agree that the county may communicate with me about this application using the contact information provided, including email and text messages, for purposes of verification, interview scheduling, and benefit notices.

Applicant Statement

By signing below, I affirm that I have read and understand the statements above; that I have provided complete and truthful information to the best of my knowledge; and that I authorize the county to make any necessary verifications to determine eligibility for Cal Fresh benefits.

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