Form CW80 "Self-certification Form for Motor Vehicles - Calworks" - California

Form CW80 is a California Department of Social Services form also known as the "Self-certification Form For Motor Vehicles - Calworks". The latest edition of the form was released in February 1, 2018 and is available for digital filing.

Download an up-to-date Form CW80 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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Download Form CW80 "Self-certification Form for Motor Vehicles - Calworks" - California

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State of California – Health and Human Services Agency
California Department of Social Services
SELF-CERTIFICATION FORM FOR MOTOR VEHICLES - CALWORKS
INSTRUCTIONS: Please provide information for each vehicle that anyone owns, has use of, or
has their name on the registration, even if it is not running. Vehicle means car (including truck, van,
sport utility vehicle [SUV]), motorcycle, motorized scooter, snowmobile, recreational vehicle (RV), or
motorboat.
Name: __________________________________________ Case Number: ___________________
VEHICLE (1)
VEHICLE (2)
VEHICLE (3)
Owner of vehicle
Name of person who uses
this vehicle
Year/ Make/ Model
Vehicle License Number
Is this vehicle:
Yes
No
Yes
No
Yes
No
If yes, you may stop,
If yes, you may stop,
If yes, you may stop,
used as a home?
sign and date this
sign and date this
sign and date this
used for self-
form.
form.
form.
employment, self-
support, or business?
needed to transport
a disabled household
member?
used to get the
household’s fuel or
water for home use
and is the main source
of fuel or water for the
family?
Is this vehicle a gift,
Yes
No
Yes
No
Yes
No
donation, or family
Gift
Gift
Gift
transfer?
Donation
Donation
Donation
You must provide proof
Family transfer
Family transfer
Family transfer
to the county. If you do
If yes, check the box
If yes, check the box
If yes, check the box
not have proof, ask the
that applies, attach
that applies, attach
that applies, attach
county for help.
proof from DMV and
proof from DMV and
proof from DMV and
stop here, sign and
stop here, sign and
stop here, sign and
date this form.
date this form.
date this form.
Estimated value of vehicle
$_______________
$_______________
$_______________
(how much your vehicle is
I don’t know/I need
I don’t know/I need
I don’t know/I need
worth)? We call this the
help finding out the
help finding out the
help finding out the
fair market value.
value.
value.
value.
CW 80 (2/18) Required Form - Substitutes Permitted
Page 1 of 2
State of California – Health and Human Services Agency
California Department of Social Services
SELF-CERTIFICATION FORM FOR MOTOR VEHICLES - CALWORKS
INSTRUCTIONS: Please provide information for each vehicle that anyone owns, has use of, or
has their name on the registration, even if it is not running. Vehicle means car (including truck, van,
sport utility vehicle [SUV]), motorcycle, motorized scooter, snowmobile, recreational vehicle (RV), or
motorboat.
Name: __________________________________________ Case Number: ___________________
VEHICLE (1)
VEHICLE (2)
VEHICLE (3)
Owner of vehicle
Name of person who uses
this vehicle
Year/ Make/ Model
Vehicle License Number
Is this vehicle:
Yes
No
Yes
No
Yes
No
If yes, you may stop,
If yes, you may stop,
If yes, you may stop,
used as a home?
sign and date this
sign and date this
sign and date this
used for self-
form.
form.
form.
employment, self-
support, or business?
needed to transport
a disabled household
member?
used to get the
household’s fuel or
water for home use
and is the main source
of fuel or water for the
family?
Is this vehicle a gift,
Yes
No
Yes
No
Yes
No
donation, or family
Gift
Gift
Gift
transfer?
Donation
Donation
Donation
You must provide proof
Family transfer
Family transfer
Family transfer
to the county. If you do
If yes, check the box
If yes, check the box
If yes, check the box
not have proof, ask the
that applies, attach
that applies, attach
that applies, attach
county for help.
proof from DMV and
proof from DMV and
proof from DMV and
stop here, sign and
stop here, sign and
stop here, sign and
date this form.
date this form.
date this form.
Estimated value of vehicle
$_______________
$_______________
$_______________
(how much your vehicle is
I don’t know/I need
I don’t know/I need
I don’t know/I need
worth)? We call this the
help finding out the
help finding out the
help finding out the
fair market value.
value.
value.
value.
CW 80 (2/18) Required Form - Substitutes Permitted
Page 1 of 2
State of California – Health and Human Services Agency
California Department of Social Services
VEHICLE (1)
VEHICLE (2)
VEHICLE (3)
How I found out the fair
For sale ads
For sale ads
For sale ads
market value:
Car dealer
Car dealer
Car dealer
Kelley Blue Book
Kelley Blue Book
Kelley Blue Book
Mechanic
Mechanic
Mechanic
Purchase price
Purchase price
Purchase price
Other:
Other:
Other:
___________
___________
___________
How much I owe on the
$_______________
$_______________
$_______________
vehicle:
I don’t know/I need
I don’t know/I need
I don’t know/I need
help finding out the
help finding out the
help finding out the
amount owed.
amount owed.
amount owed.
What I used to find the
Last bill
Last bill
Last bill
amount owed on the
Lender statement
Lender statement
Lender statement
vehicle:
Estimate
Estimate
Estimate
Other:
Other:
Other:
___________
___________
___________
Is this a leased vehicle?
Yes
No
Yes
No
Yes
No
I declare under penalty of perjury under the laws of the United States of America and the State
of California that the information given on this form is true, correct and complete to the best of
my knowledge.
Signature:
Date:
CW 80 (2/18) Required Form - Substitutes Permitted
Page 2 of 2
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