Clerical/Intake Eligibility Worker (EW): Please Give This Referral Priority Assignment

Santa Clara County Social Services Agency Department of Family and Children’s Services

CalWORKs/DFCS INTAKE REFERRAL

Client’s Name: Phone No.: Referral Date: Social Security No.: DOB: Eligibility Case No. (if applicable): Social Worker’s Name: SW No.: Phone No.#: Fax No:

Referred by (Other than Social Worker): Worker No. Phone No.: Fax No.:

This Person is applying for: Assistance Application North County CalWORKs Center 1330 W. Middlefield Rd. CalFresh 1867 Senter Road Mt. View, CA 94043 San Jose, CA 95112 (408) 278-2400 Medi-Cal (408) 758-3800 South County General Assistance General Assistance* 379 Tomkins Court 1919 Senter Road Diversion Payment Gilroy, CA 95020 San Jose, CA 95112 (408) 758-3300 (408) 758-3100 Family Reunification Program (AB 429)/

Dependency Wellness Court (DWC) * Must apply at the General Assistance Office

**Clerical/Intake Eligibility Worker (EW): Please give this referral priority assignment**

Instruction to Intake EW: After the Intake process is completed, indicate the program(s) for which client has been determined eligible, then email this form to: [email protected]

Client has been determined eligible for: CalWORKs CalFresh Medi-Cal

Family Reunification Program (AB 429)/ Diversion Payment General Assistance

Dependency Wellness Court (DWC)

(Eligibility Worker's Name) ( (Telephone Number) (Date) W o r k e r

Attention Applicant: Please bring the following items with you when you apply: DFCS File: 3rd Fastener, Left - Top SCZ 1812.doc DEBS Scan: CWES/DFCS ET - F6 DFCS Intake Referral – Rev. 4/16/15 Benefits – F1 Page 1 of 4  Non-Citizen Sponsor’s Statements  Verification documents such as:  Proof of income such as:  Identification for anyone over the age of 18 who  Pay stubs or other proof of earnings lives in the home  Social Security and Veterans Benefit Award  Social Security cards Letter  Documentation of naturalized citizenship  School grants/loan statements status/non-citizen status  Child Support papers showing award by the  Proof you applied for Disability Benefits or court Unemployment Benefits  Unemployment printouts/check stubs  School or training enrollment/attendance  Statements of any other income documentation  Rent and utility bills showing the address and person billed  Registration for work with Employment for the rent and/or utilities Development Department (EDD)  Property tax statements  Doctor’s statement  Real estate, mortgage and personal property loan  Verification about settlements such as lawsuits statements and insurance claims  Cost of medical bills or receipts  Immunization verification for all children ages  Proof of court ordered child support you pay six years and younger  Statement of school expenses for household members  Proof of pregnancy/Birth verification  Personal property and/or resource documents such as:  Marriage / Divorce documents  Vehicle registrations and payment books  Health insurance policies and premiums paid  Checking account statements  Conservator, Guardianship or Power of Attorney  Savings account statements or bank records papers  Insurance policies  Property trust deeds

DFCS File: 3rd Fastener, Left - Top SCZ 1812.doc DEBS Scan: CWES/DFCS ET - F6 DFCS Intake Referral – Rev. 4/16/15 Benefits – F1 Page 3 of 4 Are you interested in CalWORKs, CalFresh or General Assistance?

This tool is not intended to exclude or discourage anyone from applying. If you are not sure if you are eligible for CalWORKs (Cash Assistance), CalFresh, Medi-Cal, Employment Services or General Assistance (GA), please visit one of the district offices listed on the front of this form.

CalWORKs CalWORKs is a program that provides temporary cash assistance and employment services to families with minor children (under 18 yrs. of age). For families with income and property, the levels must be below certain limits. Basic Eligibility Requirements (Effective 7-1-14): Your family may be eligible for CalWORKs if:  A parent/caretaker relative cares for an eligible child who has one or both parents absent, incapacitated, deceased or unemployed.  Your family’s total resource (i.e., bank accounts, cash, homes, cars) are $2,000 or less ($3,000 if the parent/caretaker is age 60 or older).  At least one household member is a U.S. citizen or legal immigrant.  Based on your family size, your total gross income is within the income limit listed in the chart below. Family Minimum Basic Standard of Adequate Family Minimum Basic Standard of Adequate Size Care (MBSAC) Income Level Size Care (MBSAC) Income Level 1 $604 6 $1,868 2 $989 7 $2,053 3 $1,226 8 $2,234 4 $1,455 9 $2,423 5 $1,661 10 $2,631

CalFresh The CalFresh Program helps single people and families with little or no income to buy food. CalFresh benefits are issued from a plastic card that you use just like a bank card (ATM card) at the grocery store.

Basic Eligibility Requirements:

 The two charts below show the CalFresh Gross Income Limits and the Maximum Benefits per household size. The values are effective 10/1/14.

People in Gross Monthly Income Net Monthly Household Income 1 $1946 $ 973 2 $ 2622 $1311 3 $ 3300 $1650 4 $ 3976 $1988 5 $ 4652 $ 2326 6 $ 5330 $ 2665 7 $ 6006 $ 3003

DFCS File: 3rd Fastener, Left - Top SCZ 1812.doc DEBS Scan: CWES/DFCS ET - F6 DFCS Intake Referral – Rev. 4/16/15 Benefits – F1 Page 2 of 4 Maximum Amount of CalFresh That Eligible People May Receive:

 The table below is in effect October 1, 2014. It shows the most you could get if you have no income. As your income goes up, the amount of CalFresh benefits you will get goes down.

People in Household Maximum Monthly Allotment 1 $194 2 $357 3 $511 4 $649 5 $771 6 $925 7 $1,022

General Assistance

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: You may be eligible for General Assistance if:  Your income does not exceed your potential grant level set by the Santa Clara County Board of Supervisors.  Your car has a maximum fair market value of $4,650 or less following deduction of encumbrances.  Your total personal property is worth $500 or less.  You are a U.S. citizen, lawfully admitted permanent resident or undocumented trafficking victim. Note: If you are a sponsored non-citizen, your sponsor must sign a reimbursement agreement which is recorded and places a lien against any current or future real property holding.

DFCS File: 3rd Fastener, Left - Top SCZ 1812.doc DEBS Scan: CWES/DFCS ET - F6 DFCS Intake Referral – Rev. 4/16/15 Benefits – F1 Page 2 of 4