Form Cf 37 - Recertification For Calfresh Benefits Page 10
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11STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Case Name: _____________________________________
Case Number: _____________________________________
9. Medical Costs: Did anyone who gets CalFresh and is 60 years old or older, or disabled, have an increase or begin paying
medical costs? (Please Check One)
Yes
No
(If yes, complete the section below and attach proof if this is a new expense or if change is more than $25.)
Who had the cost? __________________________________ Type of cost _________________
Amount paid? ___________________ How often? ________________________
10. Child Support: Did anyone who gets CalFresh have to pay child support? (Please Check One)
Yes
No
(If yes, complete the section below and attach proof, if this is a new child support obligation or a change in the legal obligation to pay
child support or an increase in the amount of child support paid.)
Name(s) of children __________________________________________________________________________________________
What is the current amount they have to pay? $ _______________
Who paid support? ___________________________________
11. Dependent or Child Care:
Does anyone pay for care of a child, disabled adult, or other dependent so you or the other
person can go to work, school, or
look for a job? (Please Check One)
Yes
No
(If yes, please only list the amount you or anyone in your household pays out of pocket. Attach proof if provider or the out-of-pocket
amount has changed.)
Amount: $__________________ Who paid: ____________________________List dependent/child: ___________________________
12. Are you interested in applying for Medi-Cal? (Please Check One)
Yes
No
If you answer “yes”, the County will use your information to find out if you can get Medi-Cal.
13. Duplicate Benefits
Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP (federal name for food assistance
program, known as CalFresh in California) benefits in any state after September 22, 1996?
(Please Check One)
Yes
No
If yes, who? _________________________________________________________________________________________________
14. Trafficking (trading or selling) of Benefits
Have you or any member of your household ever been convicted of trafficking (trading or selling EBT cards to others) SNAP benefits of
$500 or more after September 22, 1996?
(Please Check One)
Yes
No
If yes, who? _________________________________________________________________________________________________
15. Trading Benefits for Drugs
Have you or any member of your household been found guilty of trading SNAP benefits for drugs after September 22, 1996?
(Please
Check One)
Yes
No
If yes, who? ________________________________________________________________________
16. Trading Benefits for Firearms or Explosives
Have you or any member of your household been found guilty of trading SNAP benefits for guns, ammunition, or explosives after
September 22, 1996?
(Please Check One)
Yes
No
If yes, who? _________________________________________________________________________________________________
17. Fleeing Felon
Are you or any member of your household hiding or running from the law to avoid prosecution, being taken into custody, or going to jail
for a felony crime or attempted felony crime?
(Please Check One)
Yes
No
If yes, who? _________________________________________________________________________________________________
18. Probation/Parole Violation
Have you or any member of your household been found by a court of law to be in violation of probation or parole?
(Please Check One)
Yes
No
If yes, who? _________________________________________________________________________________________________
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 3 OF 4
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