Form Cf 37 - Recertification For Calfresh Benefits Page 9
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11STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Case Name: _____________________________________
Case Number: _____________________________________
5. Are you homeless?
Yes
No If yes, do you pay shelter costs? (Please Check One)
Yes
No
6. Students: Is anyone who is applying for benefits including you attending a college or vocational school? (Please Check One)
Yes
No If yes, please provide the information below. If no, skip to the next question.
Name of Person
Enrolled Status
Is this person Working?
Name of School/Training
(
check one)
Half-time or more
NO
Less than half-time
YES,
Average work hours
Number of units:________
per week:________
Half-time or more
YES,
NO
Less than half-time
Average work hours
Number of units:________
per week:________
7. Do you or anyone you buy and prepare food with get income from a job (earned)? (Please Check One)
Yes
No
If yes, complete the section below and attach proof. List each job for each person who works. If you need more space, attach a separate
piece of paper and identify which question you are writing about. Examples include babysitting, salary, self-employment, sick pay, tips, etc.
Job #1
Job #2
Job #3
Name of Person who gets
income:
Employer Name:
k
Self-employed, chec
Self-employed, check
Self-employed, check
How often paid:
Weekly
Biweekly
Other
Weekly
Biweekly
Other
Weekly
Biweekly
Other
Monthly
Twice Monthly
Monthly
Twice Monthly
Monthly
Twice Monthly
Monthly Gross Amount of
$
$
$
Income:
Hours worked per month:
Yes
Yes
Will this income continue?
No
No
Yes
No
8. Do you or anyone you buy or prepare food with get income that does not come from a job (unearned)?
(Please Check One)
Yes
No
If yes, complete the section below and attach proof. Examples include: Social Security, Unemployment Compensation, Veteran’s Benefits,
State Disability Insurance (SDI), Child/Spousal Support, Worker’s Compensation, Loan/Gifts, Earned/Unearned Housing, Utilities, Food, etc.
Name
Source of Income
One-time or ongoing payment
How much/How often
?
8a. Will there be any changes to this income in the next six months
(Please Check One)
Yes
No
If yes, explain here: ___________________________________________________________________________________________
CF 37 (11/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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