CalFresh/MediCal/General Relief
Client Referral Form

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Thank you for the Client referral. Please complete as much information as available.

Is the Client Interested In:

Client Identifying Information:

Part A: Housing Assessment

Is the Client Housed?

Next Steps:

Once you submit this form we will contact the client within 24 hours and also provide you with an email confirming our follow-up.

To process applications, we will need the following copies of the client's and household members' documents:

Proof of Identify/Citizenship:

  • Driver's License/State ID Card (can be from another US state) or

  • Legal Permanent Resident Card (both sides) or

  • US Passport

Proof of Income:

  • All paystubs in the past 30 days

  • Award Letter (Unemployment, State Disability, Social Security)

  • Copy of Child Support Check

  • Copy of Bank Statement

  • Retirement Account/Pension Statement

  • Vehicle Registration

Proof of Expenses:

  • Rental Agreement/Receipt

  • Mortgage Bill

  • Motel Receipt

  • Utility Bill

 

Thank you for referring this client to our expert benefits enrollment service.

Thanks for submitting!