California Food Stamp Application Page 3
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5Application for Food Stamp Benefits
Applicant Information
✔ 1. Please fill out the following personal information for the person requesting food stamp benefits.
Name (Last, First, Middle)
Telephone Number (include area code)
Home Address (Street , P.O Box, Apt. #)
City, State, Zip Code
Mailing address (if different from above)
City, State, Zip Code
2. The food stamp office can provide an interpreter at no cost to you. Would you like an
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interpreter at your interview?
Yes
No
If “Yes,” what language?
___________________
3. To help us improve our services to you, please complete A, B, and C below. Check all that apply to
you. The law says we must record your ethnic group, race, and language. If you do not complete these
items, the county will do it for you. This will not affect your eligibility.
A. ETHNICITY (Everyone must also answer B)
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Are you Hispanic or Latino?
Yes
No
B. RACE/ETHNIC ORIGIN - Check all boxes that apply to you. If you do not complete
these items, the county will do it for you. This will not affect your eligibility.
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American Indian or Alaskan Native
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Black or African American
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Asian (If checked, please select one or more of the following)
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Filipino
Chinese
Japanese
Cambodian
Korean
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Vietnamese
Asian Indian
Laotian
Other Asian (specify) _______________
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Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following)
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Other (specify) ____________________
Native Hawaiian
Guamanian
Samoan
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White
C. PRIMARY LANGUAGE:
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English
Spanish
Lao
Tagalog
American Sign
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Cantonese
Cambodian
Vietnamese
Russian
Other (specify) ___________
✔ 4. Someone in the household is: (check more than one if applicable)
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Disabled
Homeless
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Elderly (60 & older)
Migrant/ Seasonal Farmworker –
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Without money for food
Has your only income stopped?
Yes
No
5. Do you have a physical or mental condition that requires special help during
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your interview with a food stamp worker?
Yes
No
✔ 6. How much is your rent or mortgage this month?
$_____________________
✔ 7. How much are your utilities this month, if separate from your rent or mortgage?
$____________
I have been informed about getting emergency food stamp benefits within three (3) days.
Signature
Date
County Use Only:
Case Name ________________________________________ Case # __________________________
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Application Type:
New
Recert
Date received by County _________________
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Screened for Expedited Service (ES)?
Yes
No
ES Eligible
Yes
No
page 1 of 3
DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED
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