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.
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Self Sufficiency Services (Public Assistance)
Physical Address
2751 Napa Valley Corporate Drive
Building A
Napa, CA 94558
Telephone Numbers for All Offices
Main: 707-253-4511
Toll Free: 800-464-4214
TTY: 1-800-877-8339
CareerPoint: 707-253-4134
Hours
Monday - Friday
8 AM - 5 PM
Closed on County Holidays
Link to a full list of our locations and hours
Auxiliary aids and services are available upon request to individuals with disabilities.