Fillable To be served without regard to race, color, (California)

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To be served without regard to race, color, (California)

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR
COUNTY USE ONLY
DISASTER CALFRESH
CASE NUMBER
WORKER
Disaster benefit period: _______________________ to __________________
DATE RECEIVED
IMPORTANT INFORMATION – READ CAREFULLY
YOUR RIGHTS AS AN APPLICANT OR RECIPIENT:
• To be served without regard to race, color, national origin,
religion, political affiliation, sex, handicap, or age, and to file a
complaint if you feel you have been discriminated against.
• To get Disaster CalFresh benefits within one to three calendar
days of the date the application is filed, if you are eligible.
• To talk about any action regarding your case with the County
Welfare Department and to ask for a state hearing within 90
days of approval or denial of application.
• To have an immediate review by a supervisor if your
application is denied.
• To file a complaint or ask for a state hearing by writing to your
County Welfare Department or by calling toll-free
1-800-952-5253. The toll-free number for the deaf (TDD) is
1-800-952-8349.
• To represent yourself at a state hearing or be represented by a
household member, friend, attorney, or any other person.
• To have another member of your household, or another adult
who knows you, complete this application. If it is completed by
an adult who is not a member of your household, attach written
approval signed by the head of household or another adult
household member.
YOUR RESPONSIBILITIES AS AN APPLICANT OR RECIPIENT:
• Answer the questions truthfully and completely, the best you
can. If you refuse to provide any of the needed information, you
will not get Disaster CalFresh benefits.
• At your interview, you must verify the identity of the head of
household, the identity of the person completing the
application, and if possible, proof of the household’s residence
and/or work address at the time of the disaster.
• You must cooperate with county, state and federal staff if you
are selected for a review after the disaster period.
• You can authorize someone to receive, or use your Disaster
CalFresh benefits. If you would like to authorize someone,
complete the information below:
NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER
ADDRESS INCLUDING CITY AND ZIP CODE
PICK UP EBT CARD ONLY
PICKUP EBT CARD TO PURCHASE
FOOD FOR HOUSEHOLD
PENALTY WARNING!!
IF YOUR HOUSEHOLD GETS DISASTER CALFRESH BENEFITS, YOU
MUST FOLLOW THE RULES LISTED BELOW. FAILING TO REPORT
INFORMATION OR MISREPRESENTATION OF FACTS CAN RESULT IN
LEGAL PROSECUTION WITH PENALTIES OF A FINE, IMPRISONMENT
OR BOTH. THE PENALTIES CAN RESULT IN DISQUALIFICATION
FROM THE PROGRAM, FINES UP TO $250,000 OR IMPRISONMENT
FOR UP TO 20 YEARS. THE DISQUALIFICATION PENALTIES ARE 12
MONT H S FO R THE FIRST VIOL A T I ON, 24 M O NTHS FOR THE
SECOND VIOLATION, AND PERMANENT DISQUALIFICATION FOR
THE THIRD VIOLATION.
• Do not give false information or withhold information to get
Disaster CalFresh benefits.
• Do not trade or sell your Disaster CalFresh benefits, or any
other issuance device.
• Do not alter your EBT card or any other issuance device to get
Disaster CalFresh benefits you are not entitled to receive.
• Do not use Disaster CalFresh benefits to buy ineligible items
such as alcoholic drinks and tobacco.
• Do not use someone else’s EBT card, or any other issuance
device for your household.
INSTRUCTIONS: Please complete the questions on this form for your expected circumstances during the
disaster benefit period shown above.
NAME (HEAD OF HOUSEHOLD)
PERMANENT HOME ADDRESS AT TIME OF DISASTER
TELEPHONE NUMBER
TEMPORARY ADDRESS TELEPHONE NUMBER
MAILING ADDRESS
TELEPHONE NUMBER
WORK ADDRESS AT THE TIME OF DISASTER
TELEPHONE NUMBER
PART A – HOUSEHOLD SITUATION. (You must check Yes or No for each question)
1. Was anyone in your household living
working
or both
(check appropriate box)
in the disaster area at the time of the disaster?
2. Are you unable to get to your household’s income or cash resources?
YES
NO
3. Have your income or cash resources been lowered, delayed or stopped
YES
NO
because of the disaster?
4. Will you be buying food and preparing meals during the disaster benefit period?
YES
NO
5. Is anyone in your household employed by ______________________________?
YES
NO
NAME OF COUNTY/STATE CALFRESH AGENCY
COUNTY USE ONLY
Disaster Application
Can the identify of the authorized
representative be verified?
YES
NO
Type of verification:
Can the head of household’s
identity be verified?
YES
NO
Type of verification:
Is permanent residence in disaster
area?
YES
NO
Type of verification:
Is work address in the disaster
area?
YES
NO
Type of verification:
Can the household’s residence be
verified?
YES
NO
Type of verification:
CF 385 (10/15) REQUIRED FORM – NO SUBSTITUTES PERMITTED
PAGE 1
________
________
PART B – HOUSEHOLD MEMBERS
5. List the names of all persons applying for Disaster CalFresh benefits. Include only persons who were
living with you at the time of the disaster. If you are temporarily staying with another household
because of the disaster, do not list members of that household. *Telling your Social Security
Number (SSN) is voluntary. It will be used for identification purposes only.
NAME (HEAD OF HOUSEHOLD) (HH)
SSN* BIRTHDATE
a.
NAME
RELATION TO HH
SSN* BIRTHDATE
b.
NAME
c.
NAME
d.
NAME
e.
NAME
f.
NAME
g.
RELATION TO HH
RELATION TO HH
RELATION TO HH
RELATION TO HH
RELATION TO HH
PART C – INCOME/RESOURCES/EXPENSES
SSN*
SSN*
SSN*
SSN*
SSN*
BIRTHDATE
BIRTHDATE
BIRTHDATE
BIRTHDATE
BIRTHDATE
6. a. What is the total amount of take home pay or other income all persons listed above have
received or will get during the disaster benefit period? $_________________
b. List all your income sources:
7. List all cash resources the persons listed above will be able to get to during the disaster benefit period.
Do not include any money listed in number 6.
Cash on Hand Savings Accounts Checking Accounts Other
$ $ $ $
8. Enter the amount of expenses for losses or damages related to the disaster which you have paid or
expect to pay during the disaster period. Do not list amounts which will be paid by someone who is not
listed above or which will be reimbursed during the disaster period. Eligible expenses may include
some of the following:
a. Expenses to repair damage to the household’s home or other property
essential to employment or self-employment of a household member. $_____________________
b. Temporary shelter expenses if the home is uninhabitable or
the household cannot reach it; $_____________________
c. Expenses for moving out of the area which was evacuated due to the disaster; $_____________________
d. Expenses related to protection of a home or business from disaster damage; $_____________________
e. Medical expenses due to personal injury. $_____________________
f. Disaster-related funeral expenses. $_____________________
g. Disaster-related pet boarding fees. $_____________________
h. Expenses related to replacing necessary personal and household
items, such as clothing, appliances, tools and education materials. $_____________________
i. Fuel for primary heating source. $_____________________
j. Clean-up items expense. $_____________________
k. Disaster-damaged vehicle expenses. $_____________________
l. Storage expenses. $_____________________
9. a. Is anyone listed above currently getting CalFresh benefits?
YES
NO
If yes, Who?_______________County__________State____ Monthly Allotment $___________
b. Did they ask for or get replacement CalFresh benefits for this month?
If yes, how much did they receive or will receive? ___________
YES
NO
YOUR CERTIFICATION
I certify that I understand the questions on the application and that my household is in need of Disaster
CalFresh benefits. I have read the above Penalty Warning (or had it read to me). I authorize the release of
any information necessary to determine the accuracy of my eligibility. If I am selected, I will fully cooperate
with county, state and federal staff in a review to be conducted after the disaster benefit period. I also
understand that I may be required to repay any benefits which are overpaid because I, another adult
household member, or the authorized representative reports incorrect or incomplete information.
I declare under penalty of perjury under the laws of the United States of America and the State of California
that the information contained on my application is true, correct, and complete.
SIGNATURE (ADULT HOUSEHOLD MEMBER OR AUTHORIZED REPRESENTATIVE) DATE
COUNTY USE ONLY
Household size for the number of
persons listed in 5 ____
Computation
A. Anticipated
Income (from 6 )
B. Accessible
Cash
Resources
(from 7 )
C. Total disaster
period income =
(A+B)
D. Total allowable
disaster-related
expenses
(from 8 )
E. Accessible
disaster period
income
(C-D)
$_______
+
$_________
$________
–
$________
=
$________
F. Maximum Disaster
Income Limit for
household size
(from Table) $________
If E is equal to or less than F, the
household is eligible.
Eligible:
YES
NO
Allotment
1. Disaster
Allotment
(from Table) $________
2. Regular
Allotment
Already –
Received $________
3. Net Disaster
Allotment =
(1–2) $________
EBT Card Number issued
#________________________
YES
NO
WORKER’S SIGNATURE DATE
WITNESS, IF YOU SIGNED WITH AN “X” DATE SUPERVISOR’S SIGNATURE DATE
CF 385 (10/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 2
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To be served without regard to race, color, (California)

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Completed 30 March 2022

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