Form Cw 42 - Statement Of Facts - Homeless Assistance
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2STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
-
STATEMENT OF FACTS
HOMELESS ASSISTANCE
Important Information
If you have no place to stay or have received a pay rent or quit notice from your landlord, you may be able to get Homeless Assistance payments limited
G
to once every 12 months, unless your homelessness is due to an exception. To get Homeless Assistance, you cannot have more than $100 in resources
and you must either be eligible for CalWORKs or appear to be eligible for CalWORKs.
Exceptions to the 12 month limit are homelessness due to: domestic violence, physical or mental illness, or uninhabitability of the home. These
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exceptions are also limited to once every 12 months. Homelessness that is directly caused by a State or Federal declared natural disaster is also an
exception.
If you received a pay rent or quit notice you may be able to get Homeless Assistance payments for up to two months of back rent.
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If you have no place to stay, you must be looking for permanent housing to get Homeless Assistance for Temporary Shelter (TS). If you find someplace to
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live, you may get money for permanent housing.
You may get TS payments for up to 16 days in a row. The first day starts when you get the first TS payment. If you stay anywhere for free, or somewhere
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other than a shelter or business which rents rooms, you can’t get a TS payment, but the days count as part of the 16 days.
To get TS payments you must rent from a person or place that is in the business of renting property.
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At the end of the 16 days, TS will stop. You will not be eligible to receive TS again for another 12 months, unless you have an exception, even if you have
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not used up all the TS benefits.
You will be asked to prove that your payments were spent on shelter. If you can’t, future payments will go to a shelter, landlord or others for you.
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Instructions: Print all answers in ink. If you need help, ask your worker.
COUNTY USE ONLY
1.
Name of Caretaker Relative (first, middle, last)
DATE RECEIVED
Aid
Message Phone
Social Security Number
Date of Birth
CO
Case Number
AU
Code
A
B
-
-
C
Mo._____ Day ____ Yr. ____
2.
What is your current or last address?
Number, Street
City
State
Zip
Case Name (Last, First)
D
Date HA Authorized
E
3.
Do you get Cash Aid?
I
I
YES
NO
Mo. _______ Day _______ Yr. _______
If "YES," in which county:
Type of HA (check)
4.
F
Did you get Homeless Assistance from any county at any time?
I
I
YES
NO
I
I
Temporary
Permanent
If "YES," complete:
I
I
TV
PV
Which county:
When:
I
I
5. Does anyone in your home get income from a job or training program or any other source?
I
I
TM
PM
YES
NO
If “YES”, list all income and who gets it below:
I
I
TU
PU
I
I
TD
PD
Start Date:________ Start Date:_______
6.
List all liquid resources you own (include cash, checks, savings or checking accounts,
Disposition:
credit union accounts, etc.). List each item and give its value.
I
Shelter arranged prior to TS
I
Vendor payment issued
7.
If you get Homeless Assistance, you may have the payment made out to you or given directly to a shelter,
I
HA denied
landlord or other for you. Check () below to tell us how you want the payment made:
I
I
I
I
To Yourself
To a Landlord
To a Shelter
Other (explain):
If you do not have a permanent home, fill out questions 8 through 12. If you are asking for back rent, skip to
questions 13 through 17.
Worker:
8. Explain where you are staying now.
Total resource value:
9. How long have you been there?
10. Do you pay for staying there?
If "YES," how much?
11.
Explain why you have no place to live.
Are you seeking permanent housing?
I
I
12.
YES
NO
Explain:
CW 42 (9/16) REQUIRED FORM - SUBSTITUTES PERMITTED
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