Forms & Publications

All Programs

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

Self Service Options Flyer - English Spanish

CalWORKs

CalWORKs Information Packet – English Spanish
This packet provides information about the CalWORKs program and you will receive when you apply for CalWORKs

SAWS 1 – Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs English
Use this form to apply for food, cash, or medical assistance.
You may also apply online at My C4Yourself.

CW 4 – Immediate Need Payment Request English Spanish
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 Spanish
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 Spanish
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 PDF  Spanish
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 Spanish
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 PDF  Spanish PDF 
This form may also be submitted online at www.C4Yourself.com

SAR 7 Addendum – Instructions and Penalties for the SAR 7 English Spanish
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 Spanish
This document provides help on how to complete the semi-annual SAR 7 Eligibility Status Report.

Voter Preference Form English PDF  Spanish
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 Spanish
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 Spanish
Use this form to apply for food, cash, or medical assistance.
You may also apply online at www.C4Yourself.com

CW 8 – Statement of Facts to Add an Additional Person English Spanish
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 Spanish
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 Spanish
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 Spanish
This form may also be submitted online at www.C4Yourself.com

SAR 7 Addendum – Instructions and Penalties for the SAR 7 English Spanish
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 Spanish
This document provides help on how to complete the semi-annual SAR 7 Eligibility Status Report.

Voter Preference Form English Spanish
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 PDF Spanish PDF 
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 Documents

Voter Preference Form English Spanish
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 Document (PDF) |
MC 219 - Important Information for Persons Requesting Medi-Cal Spanish Document (PDF)

Welfare-to-Work (WTW)

CW 61 - Authorization to Release Medical Information English Spanish
Use this document to provide verification for a WTW medical exemption

CW 61A – Physical Capacities English Spanish
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 Spanish
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 Spanish
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 and Spanish
Use this form to track your monthly WTW activity attendance

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

WTW 1 – WTW Plan Rights and Responsibilities English Spanish
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 Spanish
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 and Spanish
Use this form to track and verify your weekly job search.

SSSD 4005 - General Assistance Application  English and Spanish
Use this form to apply for cash assistance through the General Assistance Program.