Frequently Used Forms

  • Forms are organized alphabetically by form number. You can also search for a keyword or form name using your device's Find function, e.g. CTRL+F or COMMAND+F.
  • The programs that each form applies to are listed in the Program column: CF=CalFresh, MC=Medi-Cal, CW=CalWORKs.
  • Many of these forms are fillable, meaning you can type into them before printing. If you want to type into a form, download the free Adobe Acrobat Reader first for a desktop or laptop computer, or download the free Adobe Fill & Sign app first for a mobile device. 
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NUMBER PROGRAM NAME TYPE LINK
ABCDM 228 CF, MC, CW Authorization for Release of Information PDF (CDSS) English Spanish
CCFRM 604 MC Application for Health Insurance PDF (CDSS) English Spanish
CCP 2145 WTW CalWORKs Childcare Reimbursement Report PDF (CDSS) English Spanish
CF 10 CF Dependent Care Cost Affidavit PDF (CDSS) English Spanish
CF 285 CF Application for CalFresh PDF (CDSS) English Spanish
CF 37 CF Recertification for CalFresh Benefits PDF (CDSS) English Spanish
CSF 2 CF, CW General Affidavit PDF (local) English Spanish
CSF 22 CW Employment Questionnaire PDF (local) English Spanish 
CSF 23 CF, CW Statement of Gift/Loan PDF (local) English Spanish
CSF 33 CW Notice to Self-Employed Individuals PDF (local) English Spanish 
CSF 35 CF, CW Self-Employment Sworn Statement PDF (local) English Spanish
CW 2.1 NA MC, CW Notice and Agreement for Child, Spousal and Medical Support PDF (CDSS) English Spanish 
CW 2.1 Q MC, CW Support Questionnaire PDF (CDSS) English Spanish 
CW 2186A CW, WTW CalWORKs Exemption Request Form PDF (CDSS) English Spanish 
CW 2209 CW Immunization Good Cause Request Form PDF (CDSS) English Spanish 
CW 42 CW Statement of Facts - Homeless Assistance PDF (CDSS) English Spanish 
CW 61 CW, WTW Health Care Provider - Authorization to Release Medical Information PDF (CDSS) English Spanish 
CW 8 CW Statement of Facts for an Additional Person PDF (CDSS) English Spanish
CW 8 A CW Statement of Facts to Add a Child Under Age 16 PDF (CDSS) English Spanish 
E-81 Mileage WTW Mileage Record for WTW Activities PDF (local) English Spanish 
MC 382 MC Authorized Representative Form PDF (CDSS) English Spanish
SAR 7 CF, CW Eligibility Status Report (also see this guide to filling out the form) PDF (CDSS) English Spanish
SAWS 1 CF, MC, CW Application for CalFresh, Cash Aid, and/or MediCal/Health Care Programs PDF (CDSS) English Spanish
TEMP 2201 CF, CW Request for DAC/AR PDF (CDSS) English Spanish
TNB 4 CF Notice of Recertification for Transitional Nutrition Program PDF (CDSS) English Spanish
W 323 CW Non Needy Relative Statement PDF (local) English Spanish
W-73 CF, MC, CW Employer Letter English/Spanish PDF (local) English/Spanish
W-402 CW Employment History Form PDF (local) English Spanish
W-459 CF, MC, CW Electronic Communication Consent Form PDF (local) English Spanish
W-497 CW Caretaker Relatives for the AFDC Child PDF (local) English Spanish 
W-521 CF, MC, CW Authorization for Release of Information (CBO) English/Spanish PDF (local) English/Spanish
W-664 CF, MC, CW Verification of Gross Pay English/Spanish Word (local) English/Spanish