Who are you applying for? Yourself Someone Else
Applying for someone else Family Member Friend / Neighbor Client / Patient
Your Name, if applying for someone else
Phone Number, if applying for someone else
First Name *
Last Name *
Email
Phone Number *
Address *
Zip Code *
Date of Birth * MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Are you either a U.S. citizen or Legal Permanent Resident? * Yes No
Do you receive SSI/SSP benefits? * Yes No
Do you receive disability benefits? * Yes No
Have you applied for CalFresh before? * Yes No
If yes to applying, what was outcome?
Do you have a job (Include self-employment)? * Yes No
Select your Income Level per Month: * Under $900 $901 - $1,500 $1,501 - $2,500 $2,501 - $4,000 $4,001 - $4,833 Over $4,834 Prefer not to respond
Do you get money from other sources? (SSI, Social Security, VA benefits, pensions, etc.) * Yes No
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? *
Other Services
How did you find out about this CalFresh program? * Postcard in Mail Email from Sourcewise Case Manager Friend or Family Member Social Media 211 Second Harvest Santa Clara County
