AFBSummary 12443206

Submit Date 05/10/2024
Submit Time 02:12 PM
Application Number 12443206
Application Summary
Programs
Cash Aid (GA/GR)
Your Information
Main Applicant ********
What language do you prefer to read? English
What language do you prefer to speak? English
First Name ********
Middle Name
Last Name ********
Suffix
Other Names
Are you a person with a disability and need help to apply? No
Are you a person who is deaf or hard of hearing? No
Are you applying for benefits for yourself? Yes
Do you want to authorize someone to help you with your CalFresh

case?
CalFresh Authorized Representative
Do you want to name someone to get and spend your CalFresh

benefits for you?
Spend CalFresh Benefits
Do you want to authorize someone to help with your health coverage

application?
Health Coverage Authorized Representative
Are you a certified counselor, navigator, agent or broker?
Application Start Date
Organization Name
I.D. Number (if applicable)
Signature
Have you applied for Medi-Cal or other health insurance through

Covered California?
Covered California Case Number
Are you experiencing homelessness? Yes
Can you get mail where you currently stay? Yes

What county are you currently in? Los Angeles
Temporarily Mailing Address ********
Home Address
Do you get your mail at a different address?
Mailing Address
Home Phone ********
Mobile Phone (for password reset) ********
Work Phone/Alternate Phone
Email ********
Can we email you information about your application? Yes
Can we email you information about your case?
Date of Birth ********
What's your gender? Male
Gender Identity Male

Sexual Orientation Gay or Lesbian
Do you have a Social Security number? Yes
Social Security Number ********
Why don't you have a Social Security number?
Please explain.
Have you applied for an Social Security number?
Marital Status Never Married
Are you a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Do you have an eligible immigration status?
Immigration Document Type
Immigration Document Number
Have you lived in the U.S. continuously since 1996?
Are you a naturalized or derived citizen?
Are you a sponsored noncitizen?
Did the sponsor sign an I-134?

Did the sponsor sign an I-864?
Sponsor's First Name
Sponsor's Last Name
Sponsor's Phone
Does the sponsor regularly help you with money?
Amount
Does the sponsor regularly help with any of the following?
Please explain.
Do you have at least 10 years (40 quarters) of work history?
Do you have, applied for, or plan to apply for the following: T-

Visa, U-Visa, Violence Against Women Act (VAWA) petition
Did your immigration status change in the last 12 months?
What's changed?
Date of Change
Alien Number
Are you of Hispanic, Latino, or Spanish origin? No

What is your Hispanic, Latino, or Spanish origin?
What ethnic origin do you identify as?
What is your race and ethnic origin? White
Ethnic Origin
Are you a member of a federally recognized tribe?
What ethnic origin do you identify as?
Tribe Name
Did you ever get a service from, or did someone refer you to,
Indian Health Service or Tribal Health Programs?
Are you eligible to get services from the Indian Health Services,
tribal health programs or through a referral from one of these
programs?
People
People
Do you have other people living in your household? No

Household Details
Public Assistance ********
Did Foster get public assistance in California? Yes
County Los Angeles
Where did Foster get public assistance?
Facility/Shelter/Other Living Arrangement ********
Facility/Shelter/Living Arrangement Name First to serve
Expected date of release 01/01/2025
Other Situations
Additional Programs & Services

Select the programs you want to add to your application, if
any.
Select the services that interest you, if any, and someone will
follow-up.
Convictions and Felony
Convicted of receiving duplicate food assistance in any state after

09/22/1996?
Who received duplicate food assistance in any state after

09/22/1996?
Convicted of sharing or selling EBT cards worth $500 or more after

09/22/1996?
Who was guilty of trafficking (trading or selling) EBT cards

worth $500 or more after 09/22/1996?
Convicted of parole or probation violation? No
Who was guilty of a parole or probation violation?
Found guilty of trading food assistance for drugs in any state after
09/22/1996?
Who traded food assistance for drugs after 09/22/1996?
Found guilty of trading food assistance for guns, ammunitions, or

explosives after 09/22/1996?
Who traded food assistance for guns, bullets, or shells after

09/22/1996?
Had cash aid stopped for Welfare Fraud? No
Had cash aid stopped for penalty, sanctions, or noncooperation with No

eligibility requirements?
Hiding or running from the law for a felony crime or attempted No

felony crime? (This could be to avoid prosecution, being taken
into custody, or going to jail.)
Who is hiding or running from the law for a felony crime or

attempted felony crime?
Review & Submit
Expedited Food Assistance
Is your household's monthly gross income less than $150

and cash on hand, checking and savings accounts have $100
or less?
Thinking about your rent/mortgage and utilities: is your

household's gross income and liquid assets less than your
rent/mortgage and utilities?
Are you a migrant/seasonal farm worker household with

liquid assets under $100?
Immediate Need
Has their utilities shut off or a shut-off notice
Will run out of food in 3 days or less
Needs essential clothing
Needs rides to get food, clothing, medical care, or other

emergency items
Has an eviction notice or a notice to pay rent or leave
Has immediate medical needs
Is a victim of child abuse
Is a victim of domestic abuse
Is a victim of elder abuse
Is pregnant
Has other emergency which threatens health or safety
Please explain.
Interview
Do you prefer an in-person or phone interview for CalFresh?
Do you need any other arrangements due to a disability?

Voter Registration
Register to Vote No
Already Registered to Vote No
Don’t Want to Register to Vote Yes
Main Applicant Signature
First Name ********
Last Name ********
Date 05/10/2024
I confirm that I read, or had read to me, and understand and

agree to the Rights and Responsibilities.
Spouse/Other Parent/Other Aided Adult/Registered Domestic Partner Signature
First Name
Last Name
Date
You confirm that you read, or had read to you, and

understand and agree to the Rights and Responsibilities.

AFBSummary 12443206

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Submit Date 05/10/2024

Submit Time 02:12 PM

Application Number 12443206

Cash Aid (GA/GR)

Main Applicant ********

What language do you prefer to read? English

What language do you prefer to speak? English

First Name ********

Last Name ********

Are you a person with a disability and need help to apply? No

Are you a person who is deaf or hard of hearing? No

Are you applying for benefits for yourself? Yes

Do you want to authorize someone to help you with your CalFresh

Do you want to name someone to get and spend your CalFresh

Spend CalFresh Benefits

Do you want to authorize someone to help with your health coverage

Health Coverage Authorized Representative

Are you a certified counselor, navigator, agent or broker?

Application Start Date

I.D. Number (if applicable)

Have you applied for Medi-Cal or other health insurance through

Covered California Case Number

Are you experiencing homelessness? Yes

Can you get mail where you currently stay? Yes

Temporarily Mailing Address ********

Do you get your mail at a different address?

Home Phone ********

Mobile Phone (for password reset) ********

Work Phone/Alternate Phone

Can we email you information about your application? Yes

Can we email you information about your case?

Date of Birth ********

What's your gender? Male

Gender Identity Male

Do you have a Social Security number? Yes

Social Security Number ********

Why don't you have a Social Security number?

Have you applied for an Social Security number?

Marital Status Never Married

Are you a U.S. citizen or national? Yes

Date Entered U.S. (if you know)

Do you have an eligible immigration status?

Immigration Document Type

Immigration Document Number

Have you lived in the U.S. continuously since 1996?

Are you a naturalized or derived citizen?

Are you a sponsored noncitizen?

Did the sponsor sign an I-134?

Sponsor's First Name

Sponsor's Last Name

Does the sponsor regularly help you with money?

Does the sponsor regularly help with any of the following?

Do you have at least 10 years (40 quarters) of work history?

Do you have, applied for, or plan to apply for the following: T-

Did your immigration status change in the last 12 months?

Are you of Hispanic, Latino, or Spanish origin? No

What ethnic origin do you identify as?

What is your race and ethnic origin? White