California Food Stamp Application Page 4

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Application for Food Stamp Benefits
Household Information
8. Complete the following information for all persons in the home, including yourself. The County
will use this information to determine eligibility only.
Relationship
Do you buy and
Social Security
(i.e. son, wife,
prepare food
Name
Number (If none,
friend , foster
with this person?
(Last, First, Middle)
write none)
child, etc.)
Circle one Date of Birth (Circle one)
Yes / No
Male
1.
Female
Yes / No
Male
2.
Female
Yes / No
Male
3.
Female
Yes / No
Male
4.
Female
Yes / No
Male
5.
Female
Yes / No
Male
6.
Female
Yes / No
Male
7.
Female
Yes / No
Male
8.
Female
Yes / No
Male
9.
Female
Yes / No
Male
10.
Female
Income and Employment
✔ 9. Do you have or will you receive any income this month?
■ ■
■ ■
Yes
No
List all your household income below:
Name of person who gets money
How much each month?
$
$
$
$
Resources
✔ 10. How much money do you have? This includes money in bank accounts, in your home, or any
other place.
______________
$
County Use Only:
page 2 of 3
DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED

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