Forms

All forms and documents submitted/completed by the client, must be sent to Imaging.

The following forms are required for and common to all GA applications:

  1. GA 1 "Application for General Assistance"
  2. GA 14 "General Assistance Program- Rights and Responsibilities"
  3. GA 100 "Statement of Facts for General Assistance" or
  4. SAWS 2 Plus “Application for CalFresh, Cash Aid and/or Medi-Cal/Health Care Programs"
  5. SCD 41 "Identification and Intake Record"
  6. SSP 14 "Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment" 

Reminder: Additional forms may be required based on the type of GA application being filed (i.e. employable, unemployable, residence in an institution, sponsored individuals, etc.). The EW must review the corresponding handbook chapters/sections to determine what other forms are required.

 

[Refer to "DEBS Forms Packets"  for a complete list of the common forms used for Intake and RRR packets.]

GA 1

The GA 1 "Application for General Assistance" must be completed and signed by the applicant, or the applicant's Conservator to apply for General Assistance.

Note: The applicant's conservator may only sign the GA 1 if the applicant is physically unable to sign.

An applicant who is unable to sign their name shall be assisted to sign with an “X” or other mark. The “X” must be formally witnessed by two persons (this may include the conservator and EW).

GA 14

The GA 14 "General Assistance Program - Rights and Responsibilities" must be explained to the client and the client's signature must be obtained to indicate that they have been informed and are aware of what their rights and responsibilities are. Clients will also be given a GA 14 for their records.

Rights and Responsibilities explanation/signature are required at:

  • Application
  • Restoration
  • Reinvestigation/Renewal

GA 100/SAWS 2 Plus

The GA 100 “Statement of Facts for General Assistance” or the SAWS 2 Plus “Application for CalFresh, Cash Aid and/or Medi-Cal/Health Care Programs", must be signed by the applicant to determine eligibility for General Assistance.

A new Statement of Facts (SOF) is required at:

  • Application
  • Restoration
  • Reinvestigation/Renewal

SSP 14

The SSP 14 "Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment" must be explained to the client, completed by the EW, and signed by both the EW and the client. The SSP 14 is mandatory for persons required to apply for SSI/SSP.  

A new SSP 14 is required at:

  • Application
  • Restoration
  • Reinvestigation/Renewal

[Refer to "SSP 14" in the DEBS BP Handbook.]

 

Related Topics

Policies

Application Process

Eligibility Procedures

Return to Residence

Employment/Termination of Employment

Interview Requirements for Guardian/Conservators and Authorized Representatives

Responsible Relatives