Form CF385 "Application for Disaster Calfresh" - California

Form 385 is a California Department of Social Services form also known as the "Application For Disaster Calfresh". The latest edition of the form was released in October 1, 2015 and is available for digital filing.

Download an up-to-date fillable Form 385 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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Download Form CF385 "Application for Disaster Calfresh" - California

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR
COUNTY USE ONLY
DISASTER CALFRESH
CASE NUMBER
WORKER
Disaster benefit period: _______________________ to __________________
DATE RECEIVED
IMPORTANT INFORMATION – READ CAREFULLY
You can authorize someone to receive, or use your Disaster
YOUR RIGHTS AS AN APPLICANT OR RECIPIENT:
CalFresh benefits. If you would like to authorize someone,
complete the information below:
To be served without regard to race, color, national origin,
religion, political affiliation, sex, handicap, or age, and to file a
NAME OF AUTHORIZED REPRESENTATIVE
TELEPHONE NUMBER
complaint if you feel you have been discriminated against.
To get Disaster CalFresh benefits within one to three calendar
ADDRESS INCLUDING CITY AND ZIP CODE
days of the date the application is filed, if you are eligible.
To talk about any action regarding your case with the County
Welfare Department and to ask for a state hearing within 90
I
I
PICK UP EBT CARD ONLY
PICKUP EBT CARD TO PURCHASE
days of approval or denial of application.
FOOD FOR HOUSEHOLD
To have an immediate review by a supervisor if your
application is denied.
PENALTY WARNING!!
To file a complaint or ask for a state hearing by writing to your
IF YOUR HOUSEHOLD GETS DISASTER CALFRESH BENEFITS, YOU
County Welfare Department or by calling toll-free
MUST FOLLOW THE RULES LISTED BELOW. FAILING TO REPORT
1-800-952-5253. The toll-free number for the deaf (TDD) is
INFORMATION OR MISREPRESENTATION OF FACTS CAN RESULT IN
1-800-952-8349.
LEGAL PROSECUTION WITH PENALTIES OF A FINE, IMPRISONMENT
To represent yourself at a state hearing or be represented by a
OR BOTH. THE PENALTIES CAN RESULT IN DISQUALIFICATION
household member, friend, attorney, or any other person.
FROM THE PROGRAM, FINES UP TO $250,000 OR IMPRISONMENT
FOR UP TO 20 YEARS. THE DISQUALIFICATION PENALTIES ARE 12
To have another member of your household, or another adult
M O N T H S F O R T H E F I R S T V I O L A T I O N , 2 4 M O N T H S F O R T H E
who knows you, complete this application. If it is completed by
SECOND VIOLATION, AND PERMANENT DISQUALIFICATION FOR
an adult who is not a member of your household, attach written
THE THIRD VIOLATION.
approval signed by the head of household or another adult
household member.
Do not give false information or withhold information to get
Disaster CalFresh benefits.
YOUR RESPONSIBILITIES AS AN APPLICANT OR RECIPIENT:
Do not trade or sell your Disaster CalFresh benefits, or any
Answer the questions truthfully and completely, the best you
other issuance device.
can. If you refuse to provide any of the needed information, you
Do not alter your EBT card or any other issuance device to get
will not get Disaster CalFresh benefits.
Disaster CalFresh benefits you are not entitled to receive.
At your interview, you must verify the identity of the head of
Do not use Disaster CalFresh benefits to buy ineligible items
household, the identity of the person completing the
such as alcoholic drinks and tobacco.
application, and if possible, proof of the household’s residence
Do not use someone else’s EBT card, or any other issuance
and/or work address at the time of the disaster.
device for your household.
You must cooperate with county, state and federal staff if you
are selected for a review after the disaster period.
COUNTY USE ONLY
INSTRUCTIONS: Please complete the questions on this form for your expected circumstances during the
disaster benefit period shown above.
I
Disaster Application
NAME (HEAD OF HOUSEHOLD)
Can the identify of the authorized
representative be verified?
I
I
YES
NO
PERMANENT HOME ADDRESS AT TIME OF DISASTER
TELEPHONE NUMBER
Type of verification:
TEMPORARY ADDRESS
TELEPHONE NUMBER
Can the head of household’s
identity be verified?
TELEPHONE NUMBER
MAILING ADDRESS
I
I
YES
NO
Type of verification:
TELEPHONE NUMBER
WORK ADDRESS AT THE TIME OF DISASTER
Is permanent residence in disaster
area?
PART A – HOUSEHOLD SITUATION. (You must check Yes or No for each question)
I
I
YES
NO
I
I
I
1.
Was anyone in your household living
working
or both
(check appropriate box)
Type of verification:
in the disaster area at the time of the disaster?
Is work address in the disaster
area?
I
I
2.
Are you unable to get to your household’s income or cash resources?
YES
NO
I
I
YES
NO
:
Type of verification
I
I
3.
Have your income or cash resources been lowered, delayed or stopped
YES
NO
because of the disaster?
Can the household’s residence be
verified?
I
I
YES
NO
4.
Will you be buying food and preparing meals during the disaster benefit period?
I
I
YES
NO
Type of verification:
I
I
5.
Is anyone in your household employed by ______________________________?
YES
NO
NAME OF COUNTY/STATE CALFRESH AGENCY
CF 385 (10/15) REQUIRED FORM – NO SUBSTITUTES PERMITTED
PAGE 1
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR
COUNTY USE ONLY
DISASTER CALFRESH
CASE NUMBER
WORKER
Disaster benefit period: _______________________ to __________________
DATE RECEIVED
IMPORTANT INFORMATION – READ CAREFULLY
You can authorize someone to receive, or use your Disaster
YOUR RIGHTS AS AN APPLICANT OR RECIPIENT:
CalFresh benefits. If you would like to authorize someone,
complete the information below:
To be served without regard to race, color, national origin,
religion, political affiliation, sex, handicap, or age, and to file a
NAME OF AUTHORIZED REPRESENTATIVE
TELEPHONE NUMBER
complaint if you feel you have been discriminated against.
To get Disaster CalFresh benefits within one to three calendar
ADDRESS INCLUDING CITY AND ZIP CODE
days of the date the application is filed, if you are eligible.
To talk about any action regarding your case with the County
Welfare Department and to ask for a state hearing within 90
I
I
PICK UP EBT CARD ONLY
PICKUP EBT CARD TO PURCHASE
days of approval or denial of application.
FOOD FOR HOUSEHOLD
To have an immediate review by a supervisor if your
application is denied.
PENALTY WARNING!!
To file a complaint or ask for a state hearing by writing to your
IF YOUR HOUSEHOLD GETS DISASTER CALFRESH BENEFITS, YOU
County Welfare Department or by calling toll-free
MUST FOLLOW THE RULES LISTED BELOW. FAILING TO REPORT
1-800-952-5253. The toll-free number for the deaf (TDD) is
INFORMATION OR MISREPRESENTATION OF FACTS CAN RESULT IN
1-800-952-8349.
LEGAL PROSECUTION WITH PENALTIES OF A FINE, IMPRISONMENT
To represent yourself at a state hearing or be represented by a
OR BOTH. THE PENALTIES CAN RESULT IN DISQUALIFICATION
household member, friend, attorney, or any other person.
FROM THE PROGRAM, FINES UP TO $250,000 OR IMPRISONMENT
FOR UP TO 20 YEARS. THE DISQUALIFICATION PENALTIES ARE 12
To have another member of your household, or another adult
M O N T H S F O R T H E F I R S T V I O L A T I O N , 2 4 M O N T H S F O R T H E
who knows you, complete this application. If it is completed by
SECOND VIOLATION, AND PERMANENT DISQUALIFICATION FOR
an adult who is not a member of your household, attach written
THE THIRD VIOLATION.
approval signed by the head of household or another adult
household member.
Do not give false information or withhold information to get
Disaster CalFresh benefits.
YOUR RESPONSIBILITIES AS AN APPLICANT OR RECIPIENT:
Do not trade or sell your Disaster CalFresh benefits, or any
Answer the questions truthfully and completely, the best you
other issuance device.
can. If you refuse to provide any of the needed information, you
Do not alter your EBT card or any other issuance device to get
will not get Disaster CalFresh benefits.
Disaster CalFresh benefits you are not entitled to receive.
At your interview, you must verify the identity of the head of
Do not use Disaster CalFresh benefits to buy ineligible items
household, the identity of the person completing the
such as alcoholic drinks and tobacco.
application, and if possible, proof of the household’s residence
Do not use someone else’s EBT card, or any other issuance
and/or work address at the time of the disaster.
device for your household.
You must cooperate with county, state and federal staff if you
are selected for a review after the disaster period.
COUNTY USE ONLY
INSTRUCTIONS: Please complete the questions on this form for your expected circumstances during the
disaster benefit period shown above.
I
Disaster Application
NAME (HEAD OF HOUSEHOLD)
Can the identify of the authorized
representative be verified?
I
I
YES
NO
PERMANENT HOME ADDRESS AT TIME OF DISASTER
TELEPHONE NUMBER
Type of verification:
TEMPORARY ADDRESS
TELEPHONE NUMBER
Can the head of household’s
identity be verified?
TELEPHONE NUMBER
MAILING ADDRESS
I
I
YES
NO
Type of verification:
TELEPHONE NUMBER
WORK ADDRESS AT THE TIME OF DISASTER
Is permanent residence in disaster
area?
PART A – HOUSEHOLD SITUATION. (You must check Yes or No for each question)
I
I
YES
NO
I
I
I
1.
Was anyone in your household living
working
or both
(check appropriate box)
Type of verification:
in the disaster area at the time of the disaster?
Is work address in the disaster
area?
I
I
2.
Are you unable to get to your household’s income or cash resources?
YES
NO
I
I
YES
NO
:
Type of verification
I
I
3.
Have your income or cash resources been lowered, delayed or stopped
YES
NO
because of the disaster?
Can the household’s residence be
verified?
I
I
YES
NO
4.
Will you be buying food and preparing meals during the disaster benefit period?
I
I
YES
NO
Type of verification:
I
I
5.
Is anyone in your household employed by ______________________________?
YES
NO
NAME OF COUNTY/STATE CALFRESH AGENCY
CF 385 (10/15) REQUIRED FORM – NO SUBSTITUTES PERMITTED
PAGE 1
PART B – HOUSEHOLD MEMBERS
COUNTY USE ONLY
5.
List the names of all persons applying for Disaster CalFresh benefits. Include only persons who were
living with you at the time of the disaster. If you are temporarily staying with another household
because of the disaster, do not list members of that household. *Telling your Social Security
Household size for the number of
Number (SSN) is voluntary. It will be used for identification purposes only.
persons listed in 5 ____
SSN*
BIRTHDATE
NAME (HEAD OF HOUSEHOLD) (HH)
a.
SSN*
BIRTHDATE
NAME
RELATION TO HH
b.
SSN*
BIRTHDATE
NAME
RELATION TO HH
c.
SSN*
BIRTHDATE
NAME
RELATION TO HH
d.
SSN*
BIRTHDATE
NAME
RELATION TO HH
e.
SSN*
BIRTHDATE
NAME
RELATION TO HH
f.
SSN*
BIRTHDATE
NAME
RELATION TO HH
g.
PART C – INCOME/RESOURCES/EXPENSES
6.
a.
What is the total amount of take home pay or other income all persons listed above have
Computation
received or will get during the disaster benefit period?
$_________________
A.
Anticipated
b.
List all your income sources:
Income (from 6 )
$_______
B.
Accessible
Cash
Resources
+
7.
List all cash resources the persons listed above will be able to get to during the disaster benefit period.
(from 7 )
$ _________
Do not include any money listed in number 6.
C.
Total disaster
Cash on Hand
Savings Accounts
Checking Accounts
Other
period income =
(A+B)
$ ________
$
$
$
$
________
D.
Total allowable
8.
Enter the amount of expenses for losses or damages related to the disaster which you have paid or
disaster-related
expect to pay during the disaster period. Do not list amounts which will be paid by someone who is not
expenses
listed above or which will be reimbursed during the disaster period. Eligible expenses may include
some of the following:
(from 8 )
$ ________
a.
Expenses to repair damage to the household’s home or other property
E.
Accessible
essential to employment or self-employment of a household member.
$ _____________________
disaster period
b.
Temporary shelter expenses if the home is uninhabitable or
income
=
(C-D)
$ ________
the household cannot reach it;
$ _____________________
________
c.
Expenses for moving out of the area which was evacuated due to the disaster; $ _____________________
F.
Maximum Disaster
d.
Expenses related to protection of a home or business from disaster damage;
$ _____________________
Income Limit for
e.
Medical expenses due to personal injury.
$ _____________________
household size
(from Table)
$ ________
f.
Disaster-related funeral expenses.
$ _____________________
g.
Disaster-related pet boarding fees.
$ _____________________
If E is equal to or less than F, the
h.
Expenses related to replacing necessary personal and household
household is eligible.
items, such as clothing, appliances, tools and education materials.
$ _____________________
I
I
YES
NO
Eligible:
i.
Fuel for primary heating source.
$ _____________________
j.
Clean-up items expense.
$ _____________________
Allotment
k.
Disaster-damaged vehicle expenses.
$ _____________________
1.
Disaster
l.
Storage expenses.
$ _____________________
Allotment
(from Table)
$ ________
I
I
9.
a.
Is anyone listed above currently getting CalFresh benefits?
YES
NO
2.
Regular
If yes, Who?_______________County__________State____ Monthly Allotment $___________
Allotment
b.
Did they ask for or get replacement CalFresh benefits for this month?
Already
I
I
Received
$ ________
If yes, how much did they receive or will receive? ___________
YES
NO
3.
Net Disaster
YOUR CERTIFICATION
Allotment
=
I certify that I understand the questions on the application and that my household is in need of Disaster
(1–2)
$ ________
CalFresh benefits. I have read the above Penalty Warning (or had it read to me). I authorize the release of
any information necessary to determine the accuracy of my eligibility. If I am selected, I will fully cooperate
with county, state and federal staff in a review to be conducted after the disaster benefit period. I also
EBT Card Number issued
understand that I may be required to repay any benefits which are overpaid because I, another adult
household member, or the authorized representative reports incorrect or incomplete information.
# ________________________
I declare under penalty of perjury under the laws of the United States of America and the State of California
I
I
YES
NO
that the information contained on my application is true, correct, and complete.
WORKER’S SIGNATURE
DATE
SIGNATURE (ADULT HOUSEHOLD MEMBER OR AUTHORIZED REPRESENTATIVE)
DATE
WITNESS, IF YOU SIGNED WITH AN “X”
DATE
SUPERVISOR’S SIGNATURE
DATE
CF 385 (10/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 2
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