Form SAWS 1 Initial Application for Calfresh, Cash Aid, and/Or Medi-Cal/Health Care Programs - California

Form SAWS1 or the "Initial Application For Calfresh, Cash Aid, And/or Medi-cal/health Care Programs" is a form issued by the California Department of Social Services.

Download a fillable PDF version of the Form SAWS1 down below or find it on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INITIAL APPLICATION FOR CALFRESH
CASH AID
AND/OR
,
,
MEDI-CAL/HEALTH CARE PROGRAMS
If you have a disability or need help with this application, let the County Welfare Department (County) know and
someone will help you.
If you prefer to speak, read, or write in a language other than English, the County will get someone to help you
at no cost to you.
How do I apply?
Use this application if you are for applying for food assistance (CalFresh), cash aid (California Work Opportunity
and Responsibility to Kids or Refugee Cash Assistance), Medi-Cal and/or other health care programs. If you
want to apply for CalFresh only, you can ask the County for the CalFresh only application. CalFresh is a food
assistance program to help you with the cost of buying food for your household. If you want to apply for health
care only, you can ask the county for a health care only application. Health care includes: low-cost insurance for
Medi-Cal; affordable private health insurance; or a tax credit that can help you pay your premiums for health
coverage.
You can also apply for any of these programs online by going to http://www.benefitscal.org/.
• Fill out the whole application form if you can . You will be asked eligibility determination questions during your
interview. The SAWS 2 Plus form has those questions if you want to fill out the paper form (just ask the County).
You must at least give the County your name, address and signature (question 1 on page 1 of the application)
to begin the process for CalFresh. For cash aid you must fill out questions 1 through 5 on pages 1 and 2 of
the application and sign it to begin the application process.
• Each program has a symbol (shown at the top of this page) showing what questions pertain to what programs.
For cash aid, it is a dollar sign; for CalFresh, it is a shopping cart; and for health coverage, it is an ambulance.
For example, if you are not applying for cash aid, you don’t need to answer questions marked only with a dollar
sign.
• Give the application to the County in person, by mail, by fax, or online.
• The day the County receives your signed application starts the time to give you an answer on whether you can
get benefits. If you are in an institution, this time starts from the day you leave.
What do I do next?
• Read about your rights and your responsibilities (Program Rules pages) before you sign the application.
• You must have an interview with the County to discuss your application. If you have a disability, other
arrangements can be made.
• If you did not fill out all of the application, you can finish it during your interview.
• You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.
How long will it take?
It may take up to 30 days to process your application for CalFresh. For cash aid and Medi-Cal, it may take up to
45 days. Ask the County how to get your benefits or health care right away if you have an emergency.
You may be able to get CalFresh benefits within 3 calendar days if:
• Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand
or in checking or savings accounts is not more than $100; or
• Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
money in checking or savings; or
• You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your
income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.
For cash aid, you may get immediate assistance if:
• You are homeless or have an eviction notice or notice to pay rent or move; or
• Your food will run out within three days;
• Your utilities have been or will be shut off;
• You don’t have sufficient clothing or diapers;
• You have another kind of emergency important to health and safety.
Informational Page - Please take and keep for your records.
COVERSHEET PAGE 1 OF 2
SAWS 1 (8/13)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INITIAL APPLICATION FOR CALFRESH
CASH AID
AND/OR
,
,
MEDI-CAL/HEALTH CARE PROGRAMS
If you have a disability or need help with this application, let the County Welfare Department (County) know and
someone will help you.
If you prefer to speak, read, or write in a language other than English, the County will get someone to help you
at no cost to you.
How do I apply?
Use this application if you are for applying for food assistance (CalFresh), cash aid (California Work Opportunity
and Responsibility to Kids or Refugee Cash Assistance), Medi-Cal and/or other health care programs. If you
want to apply for CalFresh only, you can ask the County for the CalFresh only application. CalFresh is a food
assistance program to help you with the cost of buying food for your household. If you want to apply for health
care only, you can ask the county for a health care only application. Health care includes: low-cost insurance for
Medi-Cal; affordable private health insurance; or a tax credit that can help you pay your premiums for health
coverage.
You can also apply for any of these programs online by going to http://www.benefitscal.org/.
• Fill out the whole application form if you can . You will be asked eligibility determination questions during your
interview. The SAWS 2 Plus form has those questions if you want to fill out the paper form (just ask the County).
You must at least give the County your name, address and signature (question 1 on page 1 of the application)
to begin the process for CalFresh. For cash aid you must fill out questions 1 through 5 on pages 1 and 2 of
the application and sign it to begin the application process.
• Each program has a symbol (shown at the top of this page) showing what questions pertain to what programs.
For cash aid, it is a dollar sign; for CalFresh, it is a shopping cart; and for health coverage, it is an ambulance.
For example, if you are not applying for cash aid, you don’t need to answer questions marked only with a dollar
sign.
• Give the application to the County in person, by mail, by fax, or online.
• The day the County receives your signed application starts the time to give you an answer on whether you can
get benefits. If you are in an institution, this time starts from the day you leave.
What do I do next?
• Read about your rights and your responsibilities (Program Rules pages) before you sign the application.
• You must have an interview with the County to discuss your application. If you have a disability, other
arrangements can be made.
• If you did not fill out all of the application, you can finish it during your interview.
• You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.
How long will it take?
It may take up to 30 days to process your application for CalFresh. For cash aid and Medi-Cal, it may take up to
45 days. Ask the County how to get your benefits or health care right away if you have an emergency.
You may be able to get CalFresh benefits within 3 calendar days if:
• Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand
or in checking or savings accounts is not more than $100; or
• Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
money in checking or savings; or
• You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your
income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.
For cash aid, you may get immediate assistance if:
• You are homeless or have an eviction notice or notice to pay rent or move; or
• Your food will run out within three days;
• Your utilities have been or will be shut off;
• You don’t have sufficient clothing or diapers;
• You have another kind of emergency important to health and safety.
Informational Page - Please take and keep for your records.
COVERSHEET PAGE 1 OF 2
SAWS 1 (8/13)
To help the County see if you can get benefits faster, please complete question 1 on this form and
questions 6 through 9, 15 and 24 on the SAWS 2 PLUS. Give the County proof of your identity (if you have it)
with the application.
The County will send you a letter to let you know if your household is approved or denied for the benefits you
applied for.
What do I need for my interview?
To avoid delays, bring proof of the following items with you to your interview. Keep your interview even if you do
not have the proof. The County may be able to help if you need help getting proof. During the interview, the
County will go over the information on the application and will ask you questions to see if you can get benefits
and the amount of benefits you can get.
Proof Needed to Get Benefits
Proof Needed to Get More CalFresh Benefits
• Identification (Driver’s License, State ID card,
• Housing costs (rent receipts, mortgage bills,
passport).
property tax bill, insurance documents).
• Birth certificates for everyone applying for cash
• Phone and utility costs.
aid.
• Medical expenses for anyone in your household
• Proof of where you live (rental agreement,
who is elderly (60 and older) or disabled.
current bill with your address listed).
• Child and adult care costs due to someone
• Social Security Numbers for everyone applying
working, looking for work, attending training or
for aid (see note below about certain
school, or participating in a required work activity.
noncitizens).
• Child support paid by a person in your
• Money in the bank for all the people in your
household.
household (recent bank statements).
• Earned income of everyone in your household for
Additional Proof Needed for Health Coverage
the past 30 days (recent pay stubs, a work
• Information about any job related health
statement from an employer). NOTE: If self-
insurance available to your family.
employed, income and expenses or tax records.
• Policy numbers for any current health insurance.
• Unearned income (Unemployment benefits, SSI,
Social Security, Veteran’s benefits, child support,
Additional Proof Needed for Cash Aid
worker’s compensation, school grants or loans,
• Proof of immunizations for children six years of
rental income, etc.).
age or younger.
• Lawful immigration status ONLY for legal
• Vehicle registration for any vehicles owned by
noncitizens applying for benefits (an Alien
you or someone you are applying for.
Registration Card, visa).
NOTE: Certain noncitizens applying for
immigration status based on domestic violence,
crime prosecution or trafficking may not need this
proof. They also may not need a Social Security
number.
What if I am homeless?
Please let the County know right away if you are homeless so they can help you figure out an address to use to
accept your application and get notices from the County regarding your case. For CalFresh and cash aid,
homeless means you are:
A. Staying in a supervised shelter, halfway house, or similar place.
B. Staying at the home of another person or family for no more than 90 days straight.
C. Sleeping in a place not designed for, or normally used as, a place to sleep (a hallway, a bus station, a
lobby, or similar places).
Informational Page - Please take and keep for your records.
SAWS 1 (8/13)
COVERSHEET PAGE 2 OF 2
RIGHTS AND RESPONSIBILITIES
You have a responsibility to:
Give the County all of the information needed to determine your eligibility.
Give the County proof of the information you have when it is needed.
Report changes as required. The County will give you information about what, when, and how to report. For CalFresh
and cash aid if you don’t meet your household’s reporting requirements your case may be closed or your benefits may
be lowered or stopped.
Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your case.
cooperate with county, state, or federal personnel if your case is selected for review or investigation to ensure that
Fully
your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will result in loss of your
benefits.
Pay back any cash aid or CalFresh benefits that you were not eligible to get.
You have the right to:
Turn in an application for CalFresh giving only your name, address, and signature.
Have an interpreter provided by the State at no cost if you need one.
Have information given to the County kept confidential, unless directly related to the administration of County programs.
Withdraw your application at any time prior to the County determining eligibility.
Ask for help to fill out your application or help getting the proof that you need and get an explanation of the rules.
Be treated with courtesy, consideration and respect, and not be discriminated against.
Get CalFresh benefits within 3 days if you qualify for Expedited Service.
Get cash aid within one day if you qualify for Immediate Need.
Be interviewed in a reasonable amount of time by the county when you apply and to have your eligibility determined
within 30 days for CalFresh or 45 days for cash aid and Medi-Cal.
Get at least 10 days to give proof to the County that is needed to make a determination of eligibility.
Get written notice at least 10 days before the County lowers or stops your CalFresh or cash aid benefits.
Discuss your case with the County and to review your case when you ask to do so.
Ask for a state hearing within 90 days if you do not agree with the County about your case. If you ask for a hearing
before an action on your case takes place, your benefits will stay the same until the hearing or the end of your certification
period, whichever is earlier. You can ask the County to let your benefits change until after the hearing to avoid having to
pay back any overpaid benefits. If the Administrative Law Judge rules in your favor, the County will give back to you any
benefits that were cut.
Ask about your hearing rights or for a legal aid referral at the toll-free phone numbers – 1-800-952-5253 or for hearing
or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal aid or welfare rights
office.
Bring a friend or someone with you to the hearing if you do not want to go alone.
Get help from the County to register to vote.
Report changes that you are not required to report, if it may increase your CalFresh benefits or cash aid.
Give proof of your household’s expenses that may help you get more CalFresh benefits. Not giving proof to the County
is the same as saying that you do not have that expense and you will not be able to get more CalFresh benefits.
Let the County know if you would like someone else to use your CalFresh benefits for your household or help with your
CalFresh case (Authorized Representative).
You are also giving the Medi-Cal agency the right to pursue and get medical support from a spouse or parent. If you
think that cooperating to collect medical support will harm you or your children, you can tell the Medi-Cal agency and
you may not have to cooperate.
Please take and keep for your records
SAWS 1 (8/13)
Program Rules and Penalties
You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get
CalFresh, cash aid, and Medi-Cal, that you are not eligible to receive, or to help someone else get benefits that they are not
eligible to receive. You must pay back any benefits you get that you were not eligible to receive. If you do this on purpose
and get more than $950 in benefits that you were not eligible for you can be charged with a felony.
For CalFresh: I understand that if I commit an
intentional program violation by doing any of the
following:
I may...
hide information or make false statements
lose CalFresh benefits for 12 months for the first offense
and be required to repay all CalFresh benefits overpaid
to me
use electronic benefit transfer (EBT) cards that belong
lose CalFresh benefits for 24 months for the second
to someone else or let someone else use my card
offense and be required to repay all CalFresh benefits
overpaid to me
lose CalFresh benefits permanently for third offense and
use CalFresh benefits to buy alcohol or tobacco
be required to repay all CalFresh benefits overpaid to
me
trade, sell, or give away CalFresh benefits or EBT cards
be fined up to $250,000, imprisoned up to 20 years, or
both
lose CalFresh benefits for 24 months for the first offense
trade CalFresh benefits for controlled substances,
lose CalFresh benefits permanently for the second
such as drugs
offense.
give false information about who I am and where I live
lose CalFresh benefits for 10 years for each offense
so I can get extra CalFresh benefits
have been convicted of trading or selling CalFresh
lose CalFresh benefits forever
benefits worth more than $500, or trading CalFresh
benefits for firearms, ammunition, or explosives
For cash aid I understand that if I...
I may...
am convicted of an intentional program violation
lose my cash aid
do not follow cash aid rules
be fined up to $10,000 and/or sent to jail/prison for
5 years
am found guilty by a court of law or an administrative
lose cash aid for 6 months, 12 months, 2 years, 4 years,
hearing of committing certain types of fraud
5 years, or forever.
Important Information for Noncitizens
You can apply for and get CalFresh benefits or cash aid for people who are eligible, even if your family includes others
who are not eligible. For example, immigrant parents may apply for CalFresh benefits or cash aid for their U.S. citizen
or qualified immigrant children, even though the parents may not be eligible.
Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and
confidential.
The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S. Citizenship
and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except
cases of fraud.
Opting Out
You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s)
who are not applying for benefits. The County will need to know their income and resource information to correctly determine
your household’s benefits. The County will not contact USCIS about the people who don’t apply for benefits.
Use of Social Security Numbers (SSN)
CalFresh and Cash Aid: Everyone applying for CalFresh benefits or cash aid needs to provide a SSN, if you have one, or
proof that you have applied for a SSN (such as a letter from the Social Security office). We can deny you or any member of
your household who does not give us a SSN. Some people do not have to give SSNs to get help such as, victims of domestic
abuse, crime prosecution witnesses, and trafficking victims.
Health Coverage/Medi-Cal: We need your SSN if you want health coverage and have a SSN. Providing your SSN can be
helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income
and other information to see who’s eligible for help with health coverage costs. If someone wants help getting a SSN,
Call 1-800-772-1213 or visit the website: www.socialsecurity.gov
Overissuance
This means you got more CalFresh benefits than you should have. You will have to pay it back even if the county made an
error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of
benefits owed, through the courts, other collection agencies, or federal government collection action.
Please take and keep for your records
SAWS 1 (8/13)
Overpayment
This means that you got more cash aid than you should have gotten. Just like with CalFresh benefits, you will have to pay
it back even if the County made an error or if it wasn’t on purpose. Your cash aid may be lowered or stopped. Your SSN may
be used to collect the amount of benefits owed, through the courts, other collection agencies, or federal government collection
action.
Reporting
Every household that gets benefits must report certain changes. Your county will tell you what changes to report, how to
report them, and when to report them. Failure to report the changes may result in your benefits being lowered or stopped.
You can also report if things happen that may increase your benefits, such as getting less income.
State Hearings
You have the right to a state hearing if you do not agree with any action taken regarding your application or your ongoing
benefits. You can request a state hearing within 90 days of the County’s action and you must tell why you want a hearing.
The approval or denial notice you receive from the County will have information on how to request an appeal. If you ask for
a hearing before the action happens, you may be able to keep your cash aid and CalFresh benefits the same until a decision
is made.
Privacy Act and Disclosure
You are giving personal information in the application. The County uses the information to see if you are eligible for benefits.
If you do not give the information, the County may deny your application. You have a right to review, change, or correct any
information that you gave to the County. The County will not show your information or give it to others unless you give them
permission or federal and state law allows them to do so. The County will verify this information through computer matching
programs, including the Income and Earnings Verification System (IEVS). This information will be used to monitor compliance
with program regulations and for program management. The County may share this information with other federal and state
agencies for official examination, with law enforcement officials for the purpose of arresting persons fleeing to avoid the law,
and with private claims collection agencies for claims collection action. The County may verify immigration status of household
members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your
eligibility and level of benefits.
The County will use the information from your application to check your eligibility for help with paying for health coverage.
The County will check your answers using information in state and federal electronic databases and databases from the
Internal Revenue Service (IRS), Social Security Administration, the Department of Homeland Security, and/or a consumer
reporting agency. If the information doesn’t match, the County may ask you to send proof.
Nondiscrimination
It is the State and County’s policy that all people be treated equally, and with respect and dignity. In accordance with federal
law and the U.S. Department of Agriculture (USDA) Policy, discriminating on the basis of race, color, national origin, sex,
age, religion, political beliefs, or disabilities is strictly prohibited.
To file a complaint of discrimination, either contact your County’s Civil Rights Coordinator, or write to, or call, the USDA or
California Department of Social Services (CDSS):
CDSS
USDA, Director
Civil Rights Bureau
Office of Civil Rights, Room 326-W
P.O.BOX 944243, M.S. 8-16-70
Whitten Building
Sacramento, CA 94244-2430
1400 Independence Ave.
1-866-741-6241 (Toll Free)
Washington D.C. 20250-9410
1-202-720-5964 (voice and TDD)
USDA is an equal opportunity employer.
Work Rules for CalFresh
The county may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you
have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.
You may not be eligible for CalFresh if you have recently quit a job.
Please take and keep for your records
SAWS 1 (8/13)

Download Form SAWS 1 Initial Application for Calfresh, Cash Aid, and/Or Medi-Cal/Health Care Programs - California

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