The CalFresh Program

Sourcewise assists qualified people with low-income who meet federal income eligibility rules and want to add to their budget to put healthy and nutritious food on the table.

Our Community Resource Specialists are here to assist you with completing the registration forms needed to register for CalFresh and answer any questions you may have.

Thank you for your interest in the CalFresh Program.

Who are you applying for?YourselfSomeone Else

Applying for someone elseFamily MemberFriend / NeighborClient / Patient

Your Name, if applying for someone else

Phone Number, if applying for someone else

Please fill out the client Information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Date of Birth *

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

Do you receive SSI/SSP benefits? *YesNo

Do you receive disability benefits? *YesNo

Have you applied for CalFresh before? *YesNo

If yes to applying, what was outcome?

Income and Deductions

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

Select your Income Level per Month: *Under $900$901 - $1,500$1,501 - $2,500$2,501 - $4,000$4,001 - $4,833Over $4,834Prefer not to respond

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

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? *

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

• Information & Awareness (Find Older Adult Resources);
• Health Insurance Counseling (Medicare);
• Digital Inclusion (iPad Technology Program);
• Senior Employment Services;
• Caregivers Network;
• Meals on Wheels;
• Care Management;
• Public Authority Services;
• Senior Farmer's Market;
• Dignity at Home Fall Prevention;
• Sourcewise Transit Services;
• Other;

Other Services

How did you find out about this CalFresh program? *Postcard in MailEmail from SourcewiseCase ManagerFriend or Family MemberSocial Media211Second HarvestSanta Clara County

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