Calworks/DFCS Intake Referral

Santa Clara County Social Services Agency CalWORKs Employment Services Program CalWORKs/DFCS Partnership CalWORKs/DFCS Intake Referral

CLIENT’S NAME: TELEPHONE NUMBER:

SOCIAL SECURITY #: CASE NUMBER (if applicable): DFCS SOCIAL WORKER’S NAME: WORKER #: DFCS SW’s TEL #: FAX #:

REFERRED BY: WORKER #: REFERENT’S TEL. #: FAX #:

Assistance Application Center North County This Person is applying for: 1919 Senter Road 100 Mofett Blvd. San Jose, CA 95112 Mt. View, CA 94043 CalWORKs (408) 271-5600 (650) 988-6100 Food Stamps Medi-Cal South County General Assistance 379 Tomkins Court 1670-A Las Plumas Diversion Payment Gilroy, CA 95020 San Jose, CA 95133 Family Reunification Program (AB 429) (408) 846-3900 (408) 928-3650 General Assistance

Clerical/Intake Eligibility Worker (EW): Please give this referral priority assignment. Instruction to Intake EW: After the Intake process is completed, please indicate the program(s) the client has been determined eligible for then sign and fax this form to:  Central and North County: Karen Crawford or Patricia Phillips at (408) 975-5864.  South County: Maria Torres at (408) 846-5093.

Client has been determined eligible for: CalWORKs Food Stamps Medi-Cal Family Reunification Program (AB 429) Diversion Payment General Assistance

(Eligibility Worker's Name) (Worker #) (Telephone Number) (Date)

Attention Applicant: Please bring the following items with you when you apply:  Non-Citizen Sponsor’s Statements  Verification documents such as:  Proof of income such as:  Identification for anyone over the age of 18 who lives in  Pay stubs or other proof of earnings the home  Social Security and Veteran Benefit Award Letter  Social Security cards  School grants/loan Statements  Documentation of naturalized citizenship status/non-  Child Support papers showing awards by the courts citizen status  Unemployment printouts/stubs  Proof you applied for Disability Benefits or  Statements of any other income Unemployment Benefits  Rent and utility bills showing the address and person  School or training enrollment/attendance documentation billed for the rent and/or utilities  Registration for work with Employment Development  Property tax statements Department (EDD)  Real estate, mortgage and personal property loan  Doctor’s statement statements  Verification about settlements such as lawsuits and  Cost of medical bills or receipts insurance claims  Proof of court ordered child support you pay  Immunization verification for all children ages six years  Statement of school expense for household members and younger  Personal property and/or resource documents such as:  Proof of pregnancy/Birth verification  Vehicle registrations and payment books  Marriage / Divorce documents  Checking account statements  Health insurance policies and premiums paid  Savings account statement or bank records  Conservator, Guardianship or Power of Attorney papers  Insurance policies  Property trust deeds Scan: CWES/DFCS ET - F6 SC 1812 – 07/08 Benefits – F1 Are you interested in CalWORKs or General Assistance?

This tool is not intended to exclude or discourage anyone from applying. If there is a doubt regarding eligibility for CalWORKs (Cash Assistance, Food Stamps, Medi-Cal and Employment Services) or GA (Cash Assistance), please visit one of the district office listed on the back of this form.

What is CalWORKs?

CalWORKs (formerly AFDC) is a program that provides temporary financial assistance and employment focused services to families with minor children. For families with income and property, the levels must be below the State maximum limits.

Basic Eligibility Requirements:

Your family may be eligible for CalWORKs if:  A parent or caretaker relative may be eligible for CalWORKs if he/she cares for an eligible child who is deprived of parental support because one or both parents are absent, incapacitated, deceased or unemployed.  Based on your family size, your total gross income is within the income limit listed in the chart below.

Note: The income of an unaided caretaker relative would be excluded for CalWORKs.

Family Monthly Gross Income Limit Family Monthly Gross Income Limit Size (add $90 for each employed person) Size (add $90 for each employed person) 1 $532 6 $1,645 2 $872 7 $1,807 3 $1,080 8 $1,969 4 $1,282 9 $2,135 5 $1,464 10* $2,318 *Add $20 for each addition person

Note: Monthly Gross Income Limits are updated yearly. Income limits will be updated for Fiscal Year 08-09

 Your family’s total resource / property (i.e., bank accounts, cash on hand, savings bonds, other real property) are $2,000 or less ($3,000 if the parent / caretaker are age 60 or older).

 Your household includes a pregnant woman or a child and a parent / caretaker where at least one household member is a U.S. citizen or legal immigrant.

NOTE: If your family is potentially eligible for CalWORKs, your family is also potentially eligible for Food Stamps and Medi-Cal. Also, if your family is not potentially eligible for CalWORKs, your family may be eligible for Food Stamps and/or Medi-Cal without CalWORKs.

General Assistance

What is General Assistance (GA)?

General Assistance is a program that assists needy adults who are ineligible for State or Federal assistance. An average GA case consists of one person, living alone, with no income or resources. An emancipated foster youth or parent from whom all children have been removed could qualify for GA. The maximum monthly GA grant for one person ranges from $147 to $337, depending on your living situation.

Basic Eligibility Requirements:

 Your income is within the limit set by the Santa Clara County Board of Supervisors.  Your car is 5 years or older, or its value is $1,000 or less.  Your total personal property is worth $50 or less.  You are a U.S. citizen or permanent legal immigrant.