Form Cf 37 - Recertification For Calfresh Benefits Page 11
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11STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Case Name: __________________________________________
Case Number: _________________________________________
CERTIFICATION
Please read carefully, sign, and date. By signing this form:
I understand that by signing this recertification application under penalty of perjury (making false statements), that:
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I read, or had read to me, the information in this recertification application and my answers to the questions in this recertification
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application.
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My answers to the questions are true and complete to the best of my knowledge.
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Any answers I may give for my recertification process will be true and complete to the best of my knowledge.
I read or had read to me the Rights and Responsibilities (Program Rules Page 2) for the CalFresh Program and the CalFresh
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Program Rules and Penalties (Program Rules Pages 3 through 4).
I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for
CalFresh is fraud. Fraud can cause a criminal case to be filed against me and/or I may be barred for a period of time (or life)
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from getting CalFresh benefits.
I understand that Social Security Numbers or immigration status for household members applying for benefits may be shared
with the appropriate government agencies as required by federal law.
TO CONTINUE RECEIVING BENEFITS, YOU MUST SIGN AND DATE THIS APPLICATION AND BE
INTERVIEWED BEFORE THE LAST DAY OF YOUR CERTIFICATION PERIOD.
WHO MUST SIGN BELOW: Adult household member/Authorized Representative/Guardian
Signature or Mark of Applicant
Date
Contact email/phone
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 4 OF 4
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