Application Forms

Application Forms [63-300.2]

There are two sets of application forms available from the CDSS for CF. The sets are comprised of:

 

  • “Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs” (SAWS 1),
  • “Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs” (SAWS 2 Plus)

or

  • “Application for CalFresh Benefits” (CF 285). 
  • CalFresh Elderly Simplified Application (CF 485)

The following provides the appropriate forms to use:

  • If the client is applying for CalFresh only, then use CF 285.
  • If elderly or disabled individuals with no earned income apply for CalFresh only, use CF 485.
  • If the client is applying for CalFresh and CalWORKs/GA, then use SAWS 2 Plus.
  • If the client is applying for CalFresh and CalFresh and Medi-Cal/Health Care Insurance, then use SAWS 2 Plus.

SAWS 1

The “Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs (SAWS 1) is mainly used when a household applying for CalWORKs and CalFresh or applying for CalFresh only, where the applicant cannot complete the SAWS 2 Plus (combo programs) or CF 285 (CalFresh only) that day.

The “Application for CalFresh and Benefits” (CF 285) is used for the CalFresh only applicant households. However, if the SAWS 1 is completed by the applicant household rather than the CF 285, the County should accept the SAWS 1 as a single signature application to begin the application process and set the beginning date of aid at intake.

When the applicant’s signature has been obtained on the SAWS 1 to initiate the application process, information required on the SOF should be completed during the interactive interview. The county should not send the CF 285 or SAWS 2 Plus to require another signature.

When only the SAWS 1 is provided by the applicant, upon completion of the interactive interview, the County should provide a copy of the application to the applicant and give the applicant the opportunity to review the information and maintain for their records.

SAWS 2 Plus

The “Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs” (SAWS 2 Plus) is a joint application for CalWORKs, CalFresh, and Medi-Cal. The SAWS 2 Plus replaces the SAWS 2 and combines the program rules, many of the rights and responsibilities, the SAWS 1, the Statement of Facts, and appendices to collect additional ACA-required information where applicable.

CalFresh only applicants are required to use the CF 285. However, if applicants submit another application form, such as the SAWS 1 or SAWS 2 Plus, continue the application process and do not require applicants to complete another application form.

SAWS 2A SAR

The “Rights, Responsibilities, and Other Important Information” (SAWS 2A SAR) is a generic informational notice which includes CalFresh information on:

  • Applicant rights and responsibilities
  • The SUA
  • Job and training rules and penalties
  • IPV penalties.

There is no requirement to read or review each item of the SAWS 2A SAR with the applicant. Refer to Rights and Responsibilities for a list of the rights and responsibilities which must be reviewed with CalFresh applicants.

The SAWS 2A SAR form contains two sections for signatures. The applicant must not be asked to sign the SAWS 2A SAR form in neither of the “Applicant/Recipient Certification” sections of the form (neither a wet signature nor a telephonic signature is required).

CF 285

The “Application for CalFresh Benefits” (CF 285) is comprised of the “Coversheet”, “Program Rules and Penalties” and a 10-page Application/SOF questionnaire. The “Coversheet” and “Program Rules and Regulations” pages are located in the beginning of the application to allow the applicant to tear off these pages and keep for their records when the application is submitted to the county office. The CF 285 must be used to gather all the necessary information, including information for the ES, needed to determine the household’s eligibility for CalFresh and benefit level.

The CF 285 requires one signature for the entire application including any additional information that may be added or changed to the application. The signature page is located on the first page of the application and captures the minimum application requirement. However the applicants must be encouraged to complete as much as possible before filing the application with the county for faster determination and benefit issuance.

Refer to Minimum Application Requirements.

The CF 285 is used for the CalFresh only applicant household and is completed by the applicant or an authorized representative. The EW must review the completed form, question-by-question, with the client during the phone interview.

CF 285A

The "Prepopulated Application for CalFresh Benefits" (CF 285A) form was programmed in CalSAWS to comply with AB 79 Section 90 Provision (b). 

The CalSAWS system automatically sends the CF 285A along with the CalFresh Prepopulated Application Informational Flyer (PUB 520) to Medi-Cal recipients who are potentially eligible for CalFresh during the RE processing. 

The current system does not allow households to opt out of receiving CF 285A, even if they declined CalFresh during in-person or telephonic contact with County staff.

Upon receipt of a signed CF 285A, it should be screened for ES and registered with the "Prepopulated CalFresh" application source for tracking purposes.

CF 485

CalFresh Elderly Simplified Application (CF 485) should be used for households in which every member applying for CalFresh benefits: 

  1. Is at least 60 years or older and/or disabled,
  2. Does not receive income from work, and
  3. Purchases and prepares food together.

Note: ESAP-eligible households can apply or recertify using any CalFresh application and still be determined eligible for all other components of the ESAP. 

PUB 520

The CalFresh Prepopulated Application Informational Flyer is sent along with CF 285A to inform Medi-Cal recipients about their potential eligibility for CalFresh.

CF 23 SAR

The “CalFresh Benefits How To Report Household Changes” (CF 23 SAR) gives an explanation of the reporting responsibilities for the CalFresh program and explains:

  • Semi-Annual Reporting
  • Mandatory and Voluntary Reports

There is no requirement to review the CF 23 SAR with the applicant or to keep a copy of it in the case.

Document on the Journal Detail page that the form has been given to the applicant.

Joint CalWORKs/CalFresh Application or CalFresh/Medi-Cal/Health Care Programs

The CalFresh forms required for a joint CalWORKs/CalFresh or RCA/CalFresh or  CalFresh/Medi-Cal/Health Care Programs initial application are listed below:

  • SAWS 1*, and/or
  • SAWS 2 Plus or CSF 60, and
  • SAWS 2A SAR, and
  • “CalFresh Benefits How To Report Household Changes” (CF 23 SAR), and
  • “Would You Like to Register to Vote” (SCD 508), and
  • “Your Rights Under California Law” (PUB 13), and
  • “Informational Notice about Receiving Automatic Electronic Communications from the County of Santa Clara” (SCD 2604).

Important: The SAWS 1 is only required when a household applying for CalWORKs and CalFresh or applying for CalFresh only, when the applicant cannot complete the SAWS 2 Plus (combo programs) or CF 285 (CalFresh only) that day, the SAWS 1 would be used primarily to begin the application process and set the beginning date of aid.

Joint GA/CalFresh Application

The CalFresh forms used for a joint GA/CalFresh initial application are listed below:

  • “Application for CalFresh Benefits” (CF 285), and
  • “CalFresh Benefits How To Report Household Changes” (CF 23 SAR), and
  • “Would You Like to Register to Vote” (SCD 508), and
  • “Your Rights Under California Law” (PUB 13), and
  • “Informational Notice about Receiving Automatic Electronic Communications from the County of Santa Clara” (SCD 2604).

All Other CalFresh Applications

The forms listed below are required for any CalFresh initial application that is NOT a joint CalWORKs or RCA or GA and CalFresh application.

  • CF 285 “Application for CalFresh Benefits” or
  • SAWS 1, and
  • SAWS 2 Plus, or CSF 60 and
  • SAWS 2A SAR, and
  • CF 23 SAR “CalFresh Benefits How To Report Household Changes”, and
  • SCD 508 “Would You Like to Register to Vote”, and
  • PUB 13 “Your Rights Under California Law”, and
  • SCD 2604 “Informational Notice about Receiving Automatic Electronic Communications from the County of Santa Clara”.

Use of the CalFresh CF 285 and SCD 90 as an Application for Medi-Cal

CalFresh RECIPIENTS who want to apply for Medi-Cal may do so at any time. Timely action must be taken on ANY verbal, electronic or written request for Medi-Cal only from a CalFresh recipient on an active CalFresh case. This applies to both Intake and Continuing cases. The date of application for Medi-Cal is the date the assigned EW is first notified by the CalFresh recipient that Medi-Cal benefits are being requested, or the date the written application is received.

“Good News for California Families!” (SCD 90) Requirements

The form “Good News for California Families!” (SCD 90) is a Medi-Cal informing notice and an application for Medi-Cal. It is used for Non-Assistance CalFresh RECIPIENTS who are not enrolled in Medi-Cal.

Note: Refer to Medi-Cal (MC) Handbook regarding using a CalFresh Application for MC and complete information about the using forms SCD 90 and CF 285.

Initial Intake Applications

Intake EWs are required to explore eligibility for all programs requested and all benefits for which the applicant may qualify. If an applicant has requested CalFresh benefits, but not Medi-Cal, determine if there is potential eligibility for Medi-Cal for anyone in the household (linkage, no health insurance, etc.), and inform the applicant of their potential eligibility.

  • If the client wants to apply for Medi-Cal and CalFresh benefits have not yet been approved, then the Intake EW will provide the appropriate Medi-Cal intake packet to the client.
  • If CalFresh benefits are active and the client requests Medi-Cal while the case is still in intake, then the Intake EW will ask the client to complete and sign the SCD 90, and use the information on the CF 285 for the Medi-Cal application, if it is less than 12 months old and it contains sufficient information. Have the client complete any other required Medi-Cal forms, and issue all mandated Medi-Cal informing notices.
  • The client is NOT interested in applying, then the Intake EW will ask the client to complete a "Withdrawal Of Application" (SCD 166) or "Notice of Withdrawn Application" (CW 10). Document the reason for refusal.

Other Forms

The forms listed below may also be required:

  • CW 8 “Statement of Facts for Additional Persons”
  • SAR 22 “Sponsor's Statement of Facts Income and Resources”
  • SAR 7 “Eligibility Status Report”
  • SAR 7 Addendum “Instructions and Penalties SAR 7 Eligibility Status Report”
  • SAR 7 A “How To Fill Out Your SAR 7 Eligibility Status Report”
  • CW 8 A “Statement of Facts to Add a Child Under Age 16”
  • SAR 286 “CalFresh Budget Worksheet”
  • 842 “Claim Determination Worksheet” (required for any overissuance that occurred prior to July 15, 2009)
  • CSF 13 “Authorization for Release of Information”
  • GEN 1365 “Notice of Language Services”
  • CSF 17 “Authorization for Release of Information Financial Institutions”
  • CF 303 “Replacement Affidavit/Authorization”

Who Signs

The application must be signed by:

  • One adult household member, or
  • The Authorized Representative (AR), or
  • A responsible minor when the applicant household is composed entirely of minors and has no adult to act on its behalf.

Note: Applications containing a handwritten signature and then transmitted by fax are acceptable.

It is recommended that both adult household members sign the CF 285. Then if an IPV overissuance occurs, both individuals will have signed stating that their rights and reporting responsibilities were explained and understood.

Application Date

The date the application for CalFresh (SAWS 1/CF 285) is received in the correct county is the date of “filing” (date of application). This date starts the 30-day application processing period. If the application is submitted without the client’s signature, the date of application will be the date the county obtains the client’s signature.

Minimum Application Requirements

The application is not considered filed unless the county intake office receives an application that contains:

  • The applicant's name, and
  • Household address (unless the household is homeless), and
  • Signature of the head of household, any household member or an AR.

Note: Applications signed through the use of electronic signature techniques or applications containing a handwritten signature and then transmitted by fax or other electronic transmission are acceptable.

Applications Received from Community Based Organizations

The date of application for applications received from a CBO is the date the county intake office receives the application and meets the minimum application requirements specified in Minimum Application Requirements above. For information related to an AR designation refer to Authorized Representative.

Public Assistance (PA) Applicants [63-301.6]

A PA applicant who does not want to apply for CalFresh shall enter a signed statement to this effect, or mark the appropriate box, on the SAWS1. Even after this is done, the household's application must still be considered an application for CalFresh until it is actually determined otherwise during the interview.

Application Availability [63-300.34]

The CalFresh application form (CF 285 or SAWS 1) must be made easily accessible to potential applicants. The forms must be provided to anyone who requests an application and must be made available without having to request it (i.e. Applications must be available in the lobby). The application forms may be taken out of the office by the applicant for completion at a later time.

Related Topics

Eligibility Determination

Documentation