Forms & Publications

All Programs

General Information – English & Español
This packet provides general information when you apply for any public assistance program.

Self Service Options Flyer – English/Español

EBT 2259 – English & Español  
If you think you are a victim of electronic theft of your Electronic Benefit Transfer (EBT) benefits, fill out this form completely and return it to your Eligibility Specialist. 

EBT 2259A – English & Español
If you believe you have been scammed into giving out your EBT card number and PIN to someone who then stole benefits from your card, fill out this acknowledgment and return it to your Eligibility Specialist along with the EBT 2259 form. 

CalWORKs

CalWORKs Information Packet – English & Español
This packet provides information about the CalWORKs program, and you will receive when you apply for CalWORKs.

SSSD 2005 – Direct Deposit Information and Authorization– English & Español 
This form provides information on the benefits of using Direct Deposit. Please complete and submit page 2 of this document to enroll in Direct Deposit

SAWS 1 – Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs – English & Español 
Use this form to apply for food, cash, or medical assistance. 
You may also apply online at BenefitsCal.

CW 4 – Immediate Need Payment Request – English & Español
Complete and return this form if you have not yet been granted your CalWORKs cash assistance and feel you have a need for an immediate payment.

CW 8 – Statement of Facts to Add an Additional Person – English & Español
Use this form to add a new person (Age 16 or older) to your CalWORKs or CalFresh case.

CW 8A – Statement of Facts to Add a Child Under 16 – English & Español
Use this form to add a new child (16 years or younger) to your CalWORKs or CalFresh case.

CW 42 – Statement of Facts – Homeless Assistance – English & Español
Complete and return this form if you are currently homeless or have received a pay rent or quit notice from your landlord to access Homeless Assistance. If you are not currently in receipt of CalWORKs cash assistance, you will need to complete an application for CalWORKs also.

SAWS 2A SAR - Rights, Responsibilities and Other Important Information – English & Español
Use this form to learn more about your rights and responsibilities while you receive benefits. This form is to be signed by you and returned to SSSD.

SAR 7 – Semi-Annual Eligibility Status Report – English & Español
This form may also be submitted online at BenefitsCal.

SAR 7 Addendum – Instructions and Penalties for the SAR 7 – English & Español
This form provides you instructions for your SAR 7 and examples of information needing to be provided. It also provides information on Penalties for committing fraud.

SAR 7A – How to Fill Out Your SAR 7 Eligibility Status Report – English & Español
This document provides help on how to complete the semi-annual SAR 7 Eligibility Status Report.

Voter Preference Form – English & Español
This form tells us if you would like to register to vote or not. If you would like to register to vote, we can provide you with a voter registration card.
You may also register to vote online at www.registertovote.ca.gov.


CalFresh

CalFresh Information Packet – English & Español
This packet provides information about the CalFresh program and you will receive when you apply for CalFresh.

SAWS 1 – Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs – English & Español
Use this form to apply for food, cash, or medical assistance.
You may also apply online at BenefitsCal.

CW 8 – Statement of Facts to Add an Additional Person – English & Español
Use this form to add a new person (Age 16 or older) to your CalWORKs or CalFresh case.

CW 8A – Statement of Facts to Add a Child Under 16 – English & Español
Use this form to add a new child (16 years or younger) to your CalWORKs or CalFresh case.

SAWS 2A SAR - Rights, Responsibilities and Other Important Information – English & Español
Use this form to learn more about your rights and responsibilities while you receive benefits. This form is to be signed by you and returned to SSSD.

SAR 7 – Semi-Annual Eligibility Status Report – English & Español
This form may also be submitted online at BenefitsCal.

SAR 7 Addendum – Instructions and Penalties for the SAR 7 – English & Español
This form provides you instructions for your SAR 7 and examples of information needing to be provided. It also provides information on Penalties for committing fraud.

SAR 7A – How to Fill Out Your SAR 7 Eligibility Status Report – English & Español
This document provides help on how to complete the semi-annual SAR 7 Eligibility Status Report.

Voter Preference Form – English & Español
This form tells us if you would like to register to vote or not. If you would like to register to vote, we can provide you with a voter registration card.
You may also register to vote online at www.registertovote.ca.gov.


Medi-Cal / County Medical Services Program

Medi-Cal Information Packet – English & Español
This packet provides information about the Medi-Cal program and you will receive when you apply for Medi-Cal.

Application for Medi-Cal and Covered California health care options – All languages / todos los idiomas

Voter Preference Form – English & Español
This form tells us if you would like to register to vote or not. If you would like to register to vote, we can provide you with a voter registration card.
You may also register to vote online at www.registertovote.ca.gov.

MC 219 - Important Information for Persons Requesting Medi-Cal – English & Español


Welfare-to-Work (WTW)

CW 61 - Authorization to Release Medical Information – English & Español
Use this document to provide verification for a WTW medical exemption.

CW 61A – Physical Capacities – English & Español
This form must be included with the CW 61 if you are claiming a WTW exemption based on a physical condition.

CW 61B – Mental Capacities – English & Español
This form must be included with the CW 61 if you are claiming a WTW exemption based on a mental condition.

CW 2186A – WTW Exemption Request Form – English & Español
Use this form if you meet on of the criteria listed on this document and want to request a WTW exemption. Your worker will review and determine if you are required to participate in the WTW program.

SSSD 3000 – Monthly Participant Timecard – English/Español
Use this form to track your monthly WTW activity attendance

SSSD 3007 - Job Search Log and Mileage – English/Español
Use this form to track and verify your weekly job search.

WTW 1 – WTW Plan Rights and Responsibilities – English & Español
Use this form to learn more about your rights and responsibilities while you are on the WTW program. This form is to be signed by you and returned to SSSD.

WTW 31 – Request to Stop a WTW Sanction – English & Español
Complete and return this form to develop a plan to get your cash aid back.


General Assistance

SSSD 3007 - Job Search Log and Mileage – English/Español
Use this form to track and verify your weekly job search.

SSSD 4005 - General Assistance Application – English/Español
Use this form to apply for cash assistance through the General Assistance Program.