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


CalWORKs

CalWORKs Information PacketEnglish & Español
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 – EnglishEspañol 
Use this form to apply for food, cash, or medical assistance. 
You may also apply online at BenefitsCal.

CW 4 – Immediate Need Payment Request – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
This form may also be submitted online at BenefitsCal.

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

Voter Preference Form – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
This form may also be submitted online at BenefitsCal.

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

Voter Preference Form – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
Use this document to provide verification for a WTW medical exemption.

CW 61A – Physical Capacities – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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 – EnglishEspañol
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.