Supplemental Forms

Supplemental forms may be required when additional information is needed beyond what is asked on the MC Application.

EWs must use supplemental forms when a client answers “YES” to questions about residency, property/resources, and income.

Supplemental Forms

Usage

MC 371

This form can be used to add family members.

MC 210 S-E

This form is given to the client if any family member is attending college or a similar educational institution. Information is requested on whether the client is receiving a grant, scholarship, or loan, and any student expenses or transportation costs. This form is optional. Other school verifications may be used.

MC 210 S-I

This form serves two purposes:

  • Verifies free housing or rent paid to a relative, and this is the ONLY evidence of CA residency.
  • May be used to verify income-in-kind (including actual in-kind values when the client does not agree with the chart values).

MC 322

This form is used for property verification.

Other Required Forms/Intake Packets

In addition to the supplemental forms, the following forms and/or verifications are required depending upon the client's circumstances such as, but not limited to:

  • “Statement of Citizenship, Alienate and Immigrations Status” (MC 13) is used when citizenship cannot be verified by other documentation.

    • Note: MC 13 is not required if the applicant is requesting restricted-scope benefits.

  • Medical Support forms
    • CW 2.1 Notice and Agreement
    • CW 2.1 (Q)

      • Note: Forms must be given/sent to the client but MC benefits should not be delayed or denied for failure to provide these forms at Intake. The case can still be transferred to Continuing if the forms have not yet been received.

  • Verification of income and expense deductions.
  • Immigration status verification within 90 days.
  • Evidence of residency.

    • Note: Applicants must provide their social security number (SSN) as appropriate, but are not required to submit copies of their social security cards, unless the EW is unable to verify the number provided via MEDS or the Federal Hub.

Related Topics

HIPAA/PII

Application

Intake Documents to IDM