CalFresh Interest Form

Who are you applying for?

Applying for someone else

Your name, if applying for someone else

Your phone number, if applying for someone else

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Date of Birth *

Are you either a U.S. citizen or Legal Permanent Resident? *

Do you receive SSI/SSP benefits? *

Do you receive disability benefits? *

Have you applied for CalFresh before? *

If yes to applying, what was outcome?

Do you have a job (includes self-employment)? *

Select your Income Level per Month: *

Do you get money from other sources? (SSI, Social Security, VA benefits, pensions, etc.) *

If yes, monthly amount from SSI:

If yes, monthly amount from other sources:

Do you have medical expenses over $35/month (health insurance premium, prescriptions, etc.)? *

How much do you pay for rent/mortgage every month? *

How much do you pay for utilities? *

Do you live with anyone? *

If yes, with how many others?

How does your household member(s) get money? (job, SSI, Social Security, VA benefits, pensions, etc.)

What is the total monthly income for your household?

Please check the services below where you would like to receive more information. *

Other Services

How did you find out about this CalFresh program? *

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