PD 23-16: New Program State Forms, Revised CF State Forms

Date: 5/22/2023
To: Eligibility Staff and Clerical
From: Vivien Phan, WOOC SSA BPIS
Reference: ACL 23-26

Background

A collaborative effort between California Department of Social Services (CDSS), Department of Health Care Services (DHCS), CalSAWS, and advocate partners resulted in six new CalFresh (CF) and CalWORKs (CW) state forms. These forms may also be used by other programs as appropriate.

CDSS Civil Rights Unit (CRU) has new contact information, and four CF state forms are revised to reflect this.

New Program State Forms

See the table below for more information:

Form Number

 Form
Title		 Description Directions for Use
GEN 100 Examples of Verification The purpose of this document is to assist clients by providing examples of verification that may be necessary for eligibility determinations in each program.

Eligibility Workers (EWs) may provide GEN 100 to clients.

Reminder...Reminder... 

Verification shall not be limited to any single type of document if multiple sources are available, unless specified by program policy.
GEN 102 Appointment Letter This letter is used to notify applicants/recipients of their scheduled interview for one or more programs. EWs will select the appropriate program(s) for the interview and will specify all appointment details.
GEN 107 Message from the County The purpose of this form is to provide clients with information necessary for their case when other approved forms, letters, and notices are not sufficient.

 Information communicated to clients with this letter must still be in compliance with program requirements.

For CW...For CW...

GEN 107 can be used to communicate with the Assistance Unit (AU) or CW individual as the officially approved form when a form, letter, or NOA does not exist for the purpose intended. All rules within the CW Manual of Policies and Procedures (MPP) must be followed.

When used for purposes equivalent to a NOA, adequate and timely notice rules apply. Additionally, if used to take a negative action impacting the family receiving CW, the most current NA Back 9 must be used in conjunction with the notice.

GEN 111 Employer Statement Form This form can be used to assist clients in verifying employment and income information when other verification may not be available.

Only one employee and employer should be listed on a single form. General information for the employee and employer will be collected in Section 1, and the authorization becomes valid when signed and dated by the employee. 

EWs will mark only one of the Employer Sections boxes to indicate which sections should be completed by the employer, according to program requirements. GEN 111 may be provided to the employer either by the client or by the EW on behalf of the client.

For CW...For CW...

GEN 111 shall be used only if all other methods have been attempted or unless the client requests assistance from the county to obtain verification from the employer.
GEN 853 Sworn Statement This form may be used to assist in verifying required information by allowing clients to declare a written statement under penalty of perjury, when other verification are not available.

EWs may provide GEN 853 to clients to self-attest required program information. All programs must continue to follow verification regulation.

Important information about SCD 101 series...Important information about SCD 101 series...

  • The following forms can no longer be used for CW and CF:
    • Sworn Statement (SCD 101)
    • Sworn Statement - Continuation (SCD 101 A)
  • The following forms are obsolete and removed from DEBS Forms Library:
    • General Affidavit - Authorized Representative (Institutional Residents) (SCD 101 AR)
    • Affidavit of Citizenship (SCD 101 CZ)


For CW...For CW...

Self-attestation/sworn statements cannot be accepted for:

  1. Proof of citizenship
  2. Pregnancy verification, except as described in CW Update 22-07
  3. If the individual does not have a Social Security Number (SSN) but has applied. In the case of an SSN application, proof from the Social Security Administration is required as verification for the individual that has applied.
GEN 788
(see note)(see note)

*Not available in CalSAWS yet. GEN 788 can be found in DEBS Forms Library.

 Request to Stop My Benefits

This form may be used by a client to request a voluntary discontinuance of programs and/or services.

Additionally, the form allows for a waiver of the 10-day notice requirement to stop services for specified programs.

EWs may provide GEN 788 to clients that request a voluntary discontinuance of programs and/or services. For specified programs, a waiver for 10-day noticing can be requested. All programs must continue to follow discontinuance and noticing regulations specific to their program.

The client does not need to choose both discontinuance of a program and/or service and the 10-day waiver for GEN 788 to be complete.

Revised CF State Forms

CDSS Civil Rights Unit Contact Information

The CDSS CRU has new:

English Versions

English versions of the following forms are revised to reflect CDSS CRU's new contact information:

  • Application for CalFresh Benefits (CF 285)
  • Application for CalFresh Benefits Large Print (CF 285LP)
  • Information for Households Applying for CalFresh with the Social Security Administration (CF SSA 1)
  • Information for Households Applying for CalFresh with the Social Security Administration Large Print (CF SSA 1LP)


Staff may exhaust current stock of the English forms. Once current stock is exhausted, staff must begin using the revised English forms, which can be found on the DEBS Forms Library.

Translated Versions

Translated versions of the revised forms are not available yet.

For other languages, staff can continue using current forms until the revised translated forms are available. 

Implementation

This PD is effective immediately.