CalFresh Interest Form

Who are you applying for? *

Your name, if applying for someone else

Your phone number, if applying for someone else

Relationship to Client? *

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Date of Birth *

Sex at Birth *

Sexual Orientation *

Please Specify *

Marital status *

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

Have you ever served in the US military? *

In affiliation with someone who is serving or has served in the US military? *

If affiliated, would you like us to share your contact details with VA for additional assistance? *

What language do you feel most comfortable speaking? *

Other Language

Have you applied for CalFresh before? *

If yes to applying, what was outcome?

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

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

Total monthly income *

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

If yes, how much do you pay for your monthly medical expenses? *

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? *

The CalFresh Program