Form Cf 37 - Recertification For Calfresh Benefits Page 8
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11STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RECERTIFICATION APPLICATION - CALFRESH ONLY HOUSEHOLDS
To keep your benefits coming on time without a break, please fill out, sign, date, and return this form to the county and provide proof of
your circumstances before the end of your certification period. We need the information before or at your interview to finish the
recertification. We need at least your name, signature, address, and dated form to begin the CalFresh recertification.
Case Name: _____________________________________
Case Number: _____________________________________
MAILING ADDRESS
CITY
STATE
ZIP CODE
Contact Authorization
Please give the county the best contact information to reach you. This will help in processing your application. By providing your contact
information below, you are authorizing the county to contact you by phone, email, text,or to leave a phone message regarding your application.
HOME PHONE
CELL PHONE
CHECK BOX FOR TEXT
WORK/ALTERNATE/MESSAGE PHONE
EMAIL ADDRESS
1. Has anyone moved into or out of your home (including newborns) in the last six months? (Please Check One) Yes No
(If yes, complete the section below)
Relationship To
Regularly Purchase And
Date of Move
Name
Date Of Birth
(First, Middle, Last)
You
Prepare Food Together?
(mm/dd/yy)
In
Out
/
/
/
/
In
Out
/
/
Yes
No
/
/
In
Out
/
/
Yes
No
/
/
2. You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for
you at the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may
get by mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be replaced.
If you are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.
Do you want to name someone to help you with your CalFresh case? (Please Check One)
Yes
No If yes, complete the following section:
AUTHORIZED REPRESENTATIVE NAME
AUTHORIZED REPRESENTATIVE PHONE NUMBER
Do you want to name someone to receive and spend CalFresh benefits for your household? (Please Check One) Yes No
If yes, complete the following section:
NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
3. Have there been any changes to your address in the last six months? (Please Check One)
Yes
No If yes, complete the section below:
New Address: _________________________________________________________________Date Moved: ____________________
Mailing Address (if different from above) ___________________________________________________________________________
4. If you have moved or have new/changed housing costs in the last six months, please fill out the section below:
Your rent or mortgage per month now? $_____________
If paid separately, your property taxes and home insurance per month now? $_______________
4a. Do you have utility costs that are not included in your housing costs? If so, check which ones:
Phone
Trash
Water
Electric/Gas
Other heating or cooling costs
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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