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.

Please enable JavaScript in your browser to complete this form.

Who are you applying for? *YourselfSomeone Else

Your name, if applying for someone else

Your phone number, if applying for someone else

Relationship to Client? *

Please fill out the client information below.

First Name *

Last Name *

Email

Phone Number *

Address *

Zip Code *

Would you like to receive future updates and mailings from us? *

• Yes
• No

Date of Birth *

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Sex at Birth *MaleFemalePrefer not to respond

Sexual Orientation *Straight/HeterosexualBisexualGay/Lesbian/Same-Gender LovingQuestioning/UnsureNot listed, please specifyPrefer not to respond

Please Specify *

Marital status *Common LawDivorcedMarriedNever MarriedRegistered Domestic PartnerSeparatedSingleWidowed

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

Have you ever served in the US military? *

• Yes
• No
• Prefer not to respond

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

• Yes
• No
• Prefer not to respond

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

• Yes
• No
• Prefer not to respond

What language do you feel most comfortable speaking? *

• English
• Mandarin
• Vietnamese
• Spanish
• Other

Other Language

Have you applied for CalFresh before? *YesNo

If yes to applying, what was outcome?

Income and Deductions

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

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

Total monthly income *

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

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? *YesNo

If yes, with how many others?

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8+

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.

• Information & Awareness (locate resources in Santa Clara County);
• Care Management;
• Caregivers Network;
• Digital Link (iPad Technology Program);
• Health Insurance Counseling & Advocacy Program (Medicare);
• Meals on Wheels;
• Public Authority Services;
• Senior Employment Services;
• South County 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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