Submit Date 10/03/2024
Submit Time 09:21 AM
Application Number 15315405
Application Summary
Programs
Cash Aid (GA/GR)
Your Information
Main Applicant ********
What language do you prefer to read? English
What language do you prefer to speak? English
First Name ********
Middle Name
Last Name ********
Suffix
Other Names
Are you a person with a disability and need help to apply? No
Are you a person who is deaf or hard of hearing? No
Are you applying for benefits for yourself? Yes
Do you want to authorize someone to help you with your CalFresh
case?
CalFresh Authorized Representative
Do you want to name someone to get and spend your CalFresh
benefits for you?
Spend CalFresh Benefits
Do you want to authorize someone to help with your health coverage
application?
Health Coverage Authorized Representative
Are you a certified counselor, navigator, agent or broker?
Application Start Date
Organization Name
I.D. Number (if applicable)
Signature
Have you applied for Medi-Cal or other health insurance through
Covered California?
Covered California Case Number
Are you experiencing homelessness? Yes
Can you get mail where you currently stay? Yes
What county are you currently in? Los Angeles
Temporarily Mailing Address ********
Home Address
Do you get your mail at a different address?
Mailing Address
Home Phone
Mobile Phone (optional) ********
Work Phone/Alternate Phone
Email ********
Can we email you information about your application? Yes
Can we email you information about your case?
Date of Birth ********
What's your gender? Female
Gender Identity Female
Sexual Orientation Straight or Heterosexual
Do you have a Social Security number? Yes
Social Security Number ********
Why don't you have a Social Security number?
Please explain.
Have you applied for an Social Security number?
Marital Status Never Married
Are you a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Do you have an eligible immigration status?
Immigration Document Type
Immigration Document Number
Have you lived in the U.S. continuously since 1996?
Are you a naturalized or derived citizen?
Are you a sponsored noncitizen?
Did the sponsor sign an I-134?
Did the sponsor sign an I-864?
Sponsor's First Name
Sponsor's Last Name
Sponsor's Phone
Does the sponsor regularly help you with money?
Amount
Does the sponsor regularly help with any of the following?
Please explain.
Do you have at least 10 years (40 quarters) of work history in
the United States?
Do you have, applied for, or plan to apply for the following: T-
Visa, U-Visa, Violence Against Women Act (VAWA) petition
Did your immigration status change in the last 12 months?
What's changed?
Date of Change
Alien Number
Are you of Hispanic, Latino, or Spanish origin? No
What is your Hispanic, Latino, or Spanish origin?
What ethnic origin do you identify as?
What is your race and ethnic origin? Black or African American
Ethnic Origin
Are you a member of a federally recognized tribe?
What ethnic origin do you identify as?
Tribe Name
Did you ever get a service from, or did someone refer you to,
Indian Health Service or Tribal Health Programs?
Are you eligible to get services from the Indian Health Services,
tribal health programs or through a referral from one of these
programs?
People
People
Do you have other people living in your household? No
Income
Housing or Rent ********
Free or for work Exchange for Work
Item Value $ 10.00
Given By Friend
Utilities ********
Free or for work Exchange for Work
Item Value $ 10.00
Given By Friend
Clothing ********
Free or for work Exchange for Work
Item Value $ 20.00
Given By Community
Other Situations
Additional Programs & Services
Select the programs you want to add to your application, if
any.
Select the services that interest you, if any, and someone will
follow-up.
Convictions and Felony
Convicted of receiving duplicate food assistance in any state after
09/22/1996?
Who received duplicate food assistance in any state after
09/22/1996?
Convicted of sharing or selling EBT cards worth $500 or more after
09/22/1996?
Who was guilty of trafficking (trading or selling) EBT cards
worth $500 or more after 09/22/1996?
Convicted of parole or probation violation? No
Who was guilty of a parole or probation violation?
Found guilty of trading food assistance for drugs in any state after
09/22/1996?
Who traded food assistance for drugs after 09/22/1996?
Found guilty of trading food assistance for guns, ammunitions, or
explosives after 09/22/1996?
Who traded food assistance for guns, bullets, or shells after
09/22/1996?
Had cash aid stopped for Welfare Fraud? No
Had cash aid stopped for penalty, sanctions, or noncooperation with No
eligibility requirements?
Hiding or running from the law for a felony crime or attempted No
felony crime? (This could be to avoid prosecution, being taken
into custody, or going to jail.)
Who is hiding or running from the law for a felony crime or
attempted felony crime?
Review & Submit
Expedited Food Assistance
Is your household's monthly gross income less than $150
and cash on hand, checking and savings accounts have $100
or less?
Thinking about your rent/mortgage and utilities: is your
household's gross income and liquid assets less than your
rent/mortgage and utilities?
Are you a migrant/seasonal farm worker household with
liquid assets under $100?
Immediate Need
Has their utilities shut off or a shut-off notice
Will run out of food in 3 days or less
Needs essential clothing
Needs rides to get food, clothing, medical care, or other
emergency items
Has an eviction notice or a notice to pay rent or leave
Has immediate medical needs
Is a victim of child abuse
Is a victim of domestic abuse
Is a victim of elder abuse
Is pregnant
Has other emergency which threatens health or safety
Please explain.
Interview
Do you prefer an in-person or phone interview for CalFresh?
Do you need any other arrangements due to a disability?
Voter Registration
Register to Vote No
Already Registered to Vote Yes
Don’t Want to Register to Vote No
Main Applicant Signature
First Name ********
Last Name ********
Date 10/03/2024
I confirm that I read, or had read to me, and understand and
agree to the Rights and Responsibilities.
Spouse/Other Parent/Other Aided Adult/Registered Domestic Partner Signature
First Name
Last Name
Date
You confirm that you read, or had read to you, and
understand and agree to the Rights and Responsibilities.
