Fillable REQUEST FOR VERIFICATION (California)

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REQUEST FOR VERIFICATION (California)

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Country of origin: US
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CASE NAME:
CASE NUMBER:
WORKER NAME:
WORKER PHONE/FAX:
DATE:
REQUEST FOR VERIFICATION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
You have asked for ■■ CalWORKs (CW) ■■ CalFresh (CF) ■■ Medi-Cal (MC)
We need proof from you to see if you can get
(or keep getting)
cash aid or other benefits. We have listed the information we
need below. We will not deny or end your benefits as long as you try to get the proof and tell us if you are having problems.
We have listed types of proof on the back of this form. Sometimes we can accept other proof. Call the county if you have
questions on whether another type of proof you have will be acceptable.
Tell your worker or call the county if you are having problems getting the proof. We can help you try to get the proof.
● Give us whatever proof you do have.
● Check the box above that applies to you for what you can’t get, and turn this form in or call the county before the date
the proof is due.
● If you need the county to help get the proof, fill out the “Authorization for Release of Information” form and return it
to the county.
● For CalWORKs only: If there is a cost to get the proof, the county can pay the fee for you.
● If proof does not exist, you may be able to sign a sworn statement instead. (A sworn statement is only allowed for
certain types of proof.)
● For CalFresh only: If you cannot get proof someone outside of your household who knows the information (collateral
contact) may be contacted by the county. (A collateral contact is only allowed for certain types of proof).
If we do not get the proof or hear from you by the due dates listed above, we may have to deny, lower, or stop your
benefits.
You can get a receipt for any documents you turn in to us in person. For your records, keep a copy of this form and any proof
you mail us.
Due
Date
Item
#
Item Person
Pro-
gram
Check (✔)
the box that applies to
you
CW 2200 (2/14) REQUIRED FORM - SUBSTITUTES PERMITTED
PAGE 1
■■ CW
■■ CF
■■ MC
■■ CW
■■ CF
■■ MC
■■ CW
■■ CF
■■ MC
■■ I don’t have the proof
■■ I tried but can’t get the
proof
■■ I know somebody who
can verify this
information
■■ I have filled out the
Release form to get help
■■ I don’t have the proof
■■ I tried but can’t get the
proof
■■ I know somebody who
can verify this
information
■■ I have filled out the
Release form to get help
■■ I don’t have the proof
■■ I tried but can’t get the
proof
■■ I know somebody who
can verify this
information
■■ I have filled out the
Release form to get help
TYPES OF VERIFICATION/SOURCES OF PROOF
Listed below are examples of types of proof - you do not need to provide every document listed.
If you have other types of proof not listed, please call your worker.
Birth/Citizenship
● Birth certificate (original documents are required
for Medi-Cal)
● U.S. Passport
● Certificate of naturalization
● Baptismal certificate
(with date and place of birth)
● Statement of witness to birth
Income
● 30 days of paycheck stub(s)
● Letter from employer with gross pay, hours
worked, etc.
● Copy of child support check or payment stub
● Benefits award letter
(Social Security/
Veterans/Unemployment/Disability,etc.)
● Self-employment tax forms
(IRS Schedule C, etc.)
● Receipts for work expenses if you are
self-employed
● School grants/loans/financial aid statements
● Sponsor statement form
Immigration Status
(non-citizens)
● Immigration papers/forms/cards
(copy of both
sides)
● Other proof from immigration
(USCIS
), such as:
work authorization, letter of decision or court
order, etc.
Property/Resources
● Vehicle registration
● Proof of loans or debts/liens on property
● Statement of joint ownership
● Mortgage bill(s)
● Property deed
● Bank statements
● Life insurance policy, stocks, bonds, IRAs
● Most recent retirement account statement(s)
● Sponsor statement form
● Settlements such as lawsuits and insurance
claims
● Burial plots/crypts
Other Proof
● Child/dependent care receipts
● Statement from child/dependent care provider
● Receipts for school expenses
● Cancelled check/receipt for child/spousal support
payments
● Death certificate, obituary, witness statement of
death
● Court papers
(child support or spousal support
order)
● School attendance records
Identity
● Drivers license or Identification card
● Photo ID
(from government agency, school, etc.)
● Passport
● USCIS (INS) documents
Relationship
● Marriage certificate
● Domestic partner certificate
● Birth certificate
● Court papers
(divorce, guardianship, etc.)
Housing and Utility Costs
● Rental agreement or rent receipts
● Mortgage bill
● Utility bill
● Property tax statement
● Home or renter’s insurance bills
● Hotel/motel receipt
● Cancelled checks or copies
● Statement explaining housing arrangement
Residence
● Postmarked envelope or postcard addressed to
you
● Utility bill
● Rental agreement
● Bill or other document(s) with your name and
address
● Driver’s license or Identification card
● Eviction notice/notice to pay rent or quit
Medical Expenses
● Medical bills or receipts
● Medical transportation bills or receipts
● Health or dental insurance policies or premiums
● Medicare card
(for Medi-Cal only)
Medical Verification
● Proof of pregnancy from doctor or clinic, with
expected due date
● Doctor statement or disability finding by an agency
(SSA/SDI/VA, etc.)
● Medical verification form (CW 61)
Immunization Records
(for kids under age 6)
● Stamped shot record/Immunization card
● Statement that immunizations are against your
beliefs
● Statement from parent or caretaker relative
explaining why you can’t get immunizations
● Statement from doctor that immunizations are not
available
CW 2200 (2/14) REQUIRED FORM - SUBSTITUTES PERMITTED PAGE 2
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AUTHORIZATION FOR RELEASE OF INFORMATION
**OPTIONAL FORM**
If you cannot get the proof you need, we may be able to get it for you. Fill out this form and send it to your worker by
_________________. YOU ONLY NEED TO FILL OUT THIS FORM IF YOU WANT THE COUNTY TO CONTACT SOMEONE
FOR YOU TO GET THE PROOF YOU NEED.
If you have questions about this form, or need help filling it out, ask your worker. You can also ask your worker for more copies.
Use a separate “Authorization for Release of Information” form for each person or each agency to contact
.
To:_______________________________________,
I, ________________________________________, at ____________________________________________________
give permission to ______________________________________to give to _____________________________
information regarding ______________________________________________________________________________ .
This permission ends by __________________, or 60 days from the date signed, if no date is listed.
(Fill out form completely before signing.)
CW 2200 (2/14) REQUIRED FORM - SUBSTITUTES PERMITTED
PAGE 3
(PRINT NAME)
(ADDRESS)
(DATE)
(NAME OF AGENCY, INSTITUTION, INDIVIDUAL PROVIDER)
SIGNATURE OF APPLICANT/RECIPIENT
DATE
IF THIS IS FOR INFORMATION OF A MINOR, ENTER RELATIONSHIP TO MINOR
(COUNTY SOCIAL SERVICES DEPARTMENT)
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Completed 30 December 2022

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