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Required Forms
Intake Forms
The following forms are required for Intake.
| FORM # | FORM NAME |
| CSF 67 | EBT Card and PIN Responsibility Statement |
| EBT 2216 | EBT Surcharge Free - Direct Deposit Handout |
| PUB 13 | Your Rights Under California Welfare Programs |
| PUB 388 | California Electronic Transfer (EBT) Card |
| SCD 103 | Acknowledgment of Limited Sharing of Information for the Administration of Cash Aid Programs |
| SCD 122 | CAPI - General Eligibility Information and Payment Levels |
| SOC 453 | CAPI Statement of Household Expenses and Contributions |
| SOC 455 | CAPI - State Interim Assistance Reimbursement Authorization |
| SOC 814 | Statement of Facts - Cash Assistance Program for Immigrants (CAPI) |
| SSP 14 | Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment |
| Temp 2214 | Additional Information About EBT |
[Refer to Intake/RRR Packets for more information on required forms].
[Refer to the IAR sections for more information on Interim Assistance Reimbursement authorization forms, i.e. SSP 14 and SOC 455].
Note: As described in the Application Process, the forms SAWS 1, SCD 41 and pages 1 and 6 of SOC 814 are given up front for application registration.
State Programs-Disability Determination Service Division (SP-DDSD) Referral
The following forms are required to process a DDSD referral:
- MC 220 – Authorization for Release of Information
- MC 221 – Disability Determination and Transmittal (CAPI case to be flagged)
- MC 223 – Applicant’s Supplemental Statement of Facts for Medi-Cal
Write “CAPI CASE” in RED ink on the MC 221 in Item 8, next to the box that is checked to indicate Initial Referral.
[Refer to Medi-Cal Handbook DDSD sections for more information].
Note: A new DDSD referral is NOT needed if client’s disability-based Medi-Cal benefit is active, unless it is a sponsor-deeming disability evaluation. The EW must ensure that the reexamination date of the current DDSD determination has not expired and there is no indication that the medical condition has improved.
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