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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 |
| E-83 | WTW | Certification of Participation | 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 | |
| W-684 ORE | CF, GR | CalFresh / General Relief Employment & Training (CFET) Receipt of Orientation: Online Video | PDF (local) | English | Spanish |
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