Ca 1/dfa 285-A1 Form - Application For Cash Aid, Food Stamps, And/or Medi-Cal/34-County Cmsp Template
Download a blank fillable Ca 1/dfa 285-A1 Form - Application For Cash Aid, Food Stamps, And/or Medi-Cal/34-County Cmsp Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ca 1/dfa 285-A1 Form - Application For Cash Aid, Food Stamps, And/or Medi-Cal/34-County Cmsp Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3State of California - Health and Human Services Agency
California Department of Social Services
California Department of Health Services
COVERSHEET TO THE APPLICATION FOR CASH AID, FOOD STAMPS, AND/OR
MEDI-CAL/34-COUNTY MEDICAL SERVICES PROGRAM (CMSP)
TO APPLY FOR CASH AID, FOOD STAMPS, AND/OR
CalWORKs DIVERSION SERVICES
MEDI-CAL/34-COUNTY CMSP, complete Items 1-13 on the
Diversion services can help applicants who need some
attached application, and sign the Certification Section
assistance but do not want or need to go on welfare.
(Item 19). Give the form to the welfare office. If you have a
Diversion services allow you to choose to get a lump sum
disability and need help to apply for or keep getting cash aid,
cash payment or non-cash services instead of going on aid.
benefits, and services, tell the county.
You can only choose to get Diversion services at time of
application for cash aid, and you may be eligible for
BEFORE YOU CAN GET CASH AID, FOOD STAMPS, OR
Medi-Cal, child care assistance, and food stamps if you get
MEDI-CAL/34-COUNTY CMSP, INCLUDING IMMEDIATE
Diversion services.
NEED, HOMELESS ASSISTANCE, OR FOOD STAMP
EXPEDITED SERVICE, you must give us all the facts we
After reviewing your facts, the county will tell you if you would
ask for on your written Statement of Facts and/or answer
be eligible for Diversion services. If eligible and you choose
questions during your eligibility interview. We use the facts
to get a Diversion cash payment or non-cash services
you give us to figure eligibility and benefits.
instead of cash aid:
•
You will get a denial notice for cash aid.
FOR CASH AID AND FOOD STAMPS, the county will tell
•
Your cash aid may be lowered or the amount of time you
you if and when you need to be fingerprint and photo imaged
can get cash aid may be reduced if you go on aid later.
in order to get benefits.
TO GET IMMEDIATE NEED AND/OR HOMELESS
APPLICANTS FOR FOOD STAMPS: All you have to do
ASSISTANCE, you must appear to be eligible for Cash Aid.
the day you apply is give us your name and address, tell us
Complete the attached form and give us the facts we ask for.
you want food stamps (Item 8) and sign the application
You may need to meet some rules, such as giving us your
(Item 19). Before we can tell if you are eligible, you must
social security number(s), trying to get income available to
give us all the facts we ask for on your written Statement of
you, and agreeing to cooperate with the local child support
Facts and/or answer questions during your eligibility
agency about child, spousal, and medical support.
interview. You should be told if you are eligible within
30 days after you apply.
FOR FOOD STAMPS, the application can be filled in and
signed under penalty of perjury by either an adult household
FOOD STAMP EXPEDITED SERVICE
member or by an authorized representative. If you are not
You may have the right to get food stamps within three days.
an adult member of the household, you must have a written
Your household must be eligible for the Food Stamp Program
note signed by the head of household or another adult
AND HAVE:
household member saying that you can apply for the
•
Rent or mortgage and utility costs that are more than
household, pick up their food stamps, and/or use the food
your liquid resources and this month's income before
stamps to buy food for the household.
deductions (see the other side of the page for
FOOD STAMPS — Date of Eligibility
definitions of income and liquid resources),
If you are eligible for food stamps, we will figure your benefits
OR
from the date you apply. You can apply for food stamps the
•
No more than $100 liquid resources and less than $150
first day you contact the welfare office.
income for the month before deductions,
OR
•
No more than $100 liquid resources and at least one
CASH AID IMMEDIATE NEED
member who is a migrant or seasonal farmworker.
If you have an emergency, you may be able to get up to $200
while we work on your application. You will need to tell us
Before you can get food stamps within three days, complete
about your emergency situation and you will need to show
Items 1 - 17 on the attached application; give us all the
that you do not have the income or money to pay for these
facts we ask for during your eligibility interview; and give us
emergencies:
proof of your identity.
- Lack of housing or lack of food
MEDI-CAL PRESUMPTIVE ELIGIBILITY (PE) FOR
- Eviction notice
PREGNANT WOMEN
- No utilities or utility shut-off notice
If you are pregnant, you may get temporary Medi-Cal from
- Lack of essential clothing
certain medical providers for many prenatal care services
- Essential transportation needs not met
before applying for regular Medi-Cal. Ask your doctor or
- Other kinds of emergencies important to health and
clinic if they offer PE. If you apply for CalWORKs or Medi-Cal
safety.
by the end of the month after the month you get a PE card,
If your Immediate Need request is turned down, you can ask
your temporary Medi-Cal will continue until aid is approved
for it again during the time we work on your application. Let
or denied. If you are getting PE, tell the county and check
the county know if something changes.
“YES” in both parts of Item 12.
CASH AID HOMELESS ASSISTANCE
MEDI-CAL/34-COUNTY CMSP - MEDICAL
If you are homeless, or have received a Pay Rent or Quit
EMERGENCY/PREGNANCY
Notice, and want to apply for homeless assistance, tell the
If you have a medical emergency or are pregnant AND want
county. Homeless Assistance is available once in a lifetime,
Medi-Cal/34-County CMSP as soon as possible, complete
with exceptions.
Items 1-13. You must also give all the facts we ask for during
your eligibility interview and meet all eligibility requirements.
SAWS 1 COVERSHEET (12/06) CA 1/DFA 285-A1 REQUIRED FORM - SUBSTITUTE PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Temp 2201 - Cash Aid/food Stamp Electronic Benefit Transfer - Ebt Request For A Designated Alternate Card Holder/authorized Representative
Legal
Form Ap-175 - Texas Application For Non-retailer Cigarette, Cigar And/or Tobacco Products Permit - 2013
Financial
Application For Exemption From City Sales And/or Use Tax Form - City Of Colorado Springs Sales Tax Division
Financial
Application For Permission To File Sales And/or Use Tax Returns On A Calendar Quarter Basis Form
Financial
Form Ap-175 Texas Application For Non-retailer Cigarette, Cigar, And/or Tobacco Products Permit Instruction
Financial
Form Sf-0953 - Application For Disabled Person License Plate And/or Placard Form - Department Of Safety - Tennessee
Legal
Related Categories
Parent category: Legal