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FOOD STAMP HANDBOOK

Handbook _

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 285-A1 (11/83)

State of Catifornia Dapartment of Sociai Services Health and Welfare Agency

APPLICATION FOR FOOD STAMPS

PART 1 COUNTY USE ONLY CREE HORABER Please complete all questions in ink, DATE RECENED Step 1. Compiate Part 1. Step 2. Complete Part 2.

To begin to apply for food stamps, compiate this page and give it to Part 2 must ba complated before we can see if you are eligible for us. If you are not receiving food stamps or if you did not reapply on food stamps. You can return Part 2 to us along with this page or at time, we are raquired to take action on your application within the time of your interview. Try to fill out as much as passibie befora 30 days from tha date you give us this page. The sooner you give you give it to us. Your worker will help you with the rest during your us this page, the sooner you will know if you will recaive food interview,

stamps. Now go to Stap 2.

NAME: LAST FIRST

MISOLE HATAC TELEPHONE NUMBER

‘ADDRESS! NUMBER, STREET, ROUTE NUMBER cry Stat BP cope

‘MAILING ADDRESS {iF DIFFERENT FROM AdOVE)

“FRIAYONETHEAD UF ROVREREID, HOUSEHOLD MEMGER GR AUTHOARED REPRESENTATIVE)

DATE

ANSWER THE FOLLOWING QUESTIONS IF YOUR HOUSEHOLD HAS LITTLE OR NO INCOME AND NEEDS FOOD STAMPS IMMEDIATELY.

If your housshold (you and the people who live and eat with you) has {little or no money right now, you may be able to receive food stamps within five calendar days. .

1, Haw much do you and the members of your household have in liguid resources, such as: cash, money in checking accounts, gavings accounts, or savings certiticates; trust deeds, notes raceivabie, stocks or bonds? (Give your best estimate of the total)

s 2. How many peopia living im your home eat with your {including yoursaily

3. Has anyone in your household recaived any income go far this month?

Dives © No HYES, how much? _¢ 4, Does anyone in your household expact to receive income later this month?

Gives C)Ne © Don't Know (f{YES, how much? When? §. Is anyone in your household a migrant of seusanal farmworker?

i Cyas OC No _!f YES, who? §. Has your household's only income stopped?

ves 0 No COUNTY USE ONLY

DFA 285-A1 (11/83) Required Farm - No Substitutes Parmitied

Effective 2/15/84: