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FOOD STAMP HANDBOOK

Handbook _FORMS AND INSTRUCTIONS

_83-1230 (Cont)

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

63-1230

DFA 285-A2 (12/83)

State of Caltfornia Health and Welfara Agency

Department of Social Services

APPLICATION FOR FOOD STAMPS - PART 2 IMPORTANT: SEE PAGE & FOR INFORMATION CONCERNING YOUR RIGHTS

COUNTY USE ONLY

AND RESPONSIBILITIES. INSTRUCTIONS:

CASE NUMaaER WORKER Bate RECERED

Ol newarucation EXPEDITED SERVICE 0 recennricanon Dyes © No

DOCUMENTATION GUIDELINES identity, residency, SSN, allen status, 80 of over, dipabled

o WAME THEAD OF HOUSEHDLD:

‘ADDAESS: NUMBER, STREET, ROUTE NUMBER

cry ‘STATE ‘ZP CODE MAILING ADDRESS ((F CHFFERENT} (Q) Hes anyone living in the home received food clamps this Monin a the previous month? O ves © No

H YES, where?

Provide the foltowing information on aach person living in tha home, Including yourself, You must list Bi people in the home whether of not they want food stamps, For gach perion whe is nots aicent yOu Must provide verification of alien status,

@

Work Exemption Codi . Under 18760 or older |. Mantally/physically disabled » Cares for child under 12 oF incapacitated person . Cares for child under 18 and HH member reg/amp . Registerad/Cash Aid

. UIB registered . Participant in drug/alcohol program |. 30 hour week/min x 30

Meets atigible student criteria

Non-Household Mamber Coda

C-za7m o app

Work Ragistration Information or

be used in computer matching and program reviews or audits to ensure issuance of ben of other federal assistance programs: guch as: school lunch, AFDC or

Medi-Cal. Fraudut enrovide an SSN

1. NAME HEAD OF HOUSEHOLD) ‘BIRTHOATE US. CITE DFA 285-C LL 0 Yes © No SORAT EECUNTTY NOMOER? GiacLE Sex M_oF Tae GTHOATE U's. TEN A D yes 0 Ne OAL BEGURTTY NOMGER FELATIONSHIP TO EAD OF nGURENOLD GiRCLE SEX M oF 3 NAME OaHOATE Ws GEN / C) Yes 0 No ‘SOCIAL SECURITY NUMBER" RELATIONSHIP TQ HEAD OF HOUSEHOLD CIRCLE BEX : M_oF Tene BTDATE Wa eran fof Ci Yes © No ‘SOCIAL SECURITY NUMBER RECATIONGHIP TO HEAD OF NOUSEROLD BWRCLE BEX MF lame BRIOATE We GrEN i O Yes 0 No ‘SOCIAL SECURITY NUMEER: FECATONSHIF TS READ OF noUBENOLD TinCLE BER Non-Housshoid Mamber Codon M oF 1. ine Bane BiTROATE OE crnden 2. ineligible student . SBI/SSP recipient / / D Yes [ No 3S fi SOCIAL SECUATTY NUMBER" RELATIONSHIP TO HEAD GF HOUSEHOLD CHRCLE BEX 4. Olsqualitied/SSN or fraud : 5. Uve-in attendant MF 6. Roomer Must aiso be 7 eaMe SWTHOATE US oan 7. Excluded boarder? listed in 12 4 Cl Yes 1 No 8. Separate household SOCIAL SECURITY HOMBER® RELATIONSHIP TG HEAO OF NOUsENDLD GREE SEX (purchase/ prepare} Mor 9. Separate household (etderty/dieabled) 10. Questionable citizenship is anyone currently on sirike? i 2) GF Yes- 1 No | nate household member H_YES, who? went on strike: ® Has anyone bacarne unemployed in the last 60 days? O ves O No If YES, who?, When? Vol. Quit! © yes (Ci No © |e avons panicinating in's Food Distribution Program opersied by an indian reservation O Yes OG No if YES, who? o) Has anyone sold, traded, or given away anything ol value in the leatS months? O Yes ONo 4 W YES, explain wha and what: Household Size: iSCiOSUre fal Sacurhty Number 18 require: je Food stam; a AS SIMBA y Public Law 57-98, Tor sath lood siamp Nousano mamber. these SSNa wil oe usad toned Meaty area te ree participation ang to make charges: Te Gets cn ‘any other information provided. will atso

efits to eligible individuals partcipat Hert participation in the Food ill trawl in disqusiification of the individual for

ing in the Food Stamp Program Stamp Program may rasult in crimins! whomitis fot provided.

OFA 285-A2 (12/83) Required fornt - No Substitutes Permitied

CALIFORNIA-DSS-MANUAL-SS_ Rev. 1347 replaces Issue 2169

Effective 2/16/84