CalFresh Referral Form

CalFresh Food Referral

Please fill out the form below to refer someone to the CalFresh Food Program

Referrer Information
Referrer Name (optional)
Referrer Agency (optional)
Referrer Email (optional)
Referrer Zip Code*
I would like to refer the following person to be contacted about CalFresh Food
Total number of people in applicant's household who purchase and prepare food together*
Total monthly gross income for all household members(combined)*
Is there at least one member in applicant's household that is a U.S. Citizen, Legal Permanent Resident, Refugee or Asylee?*
- Yes
- No
Are there any members of your householdwho receive SSI (Supplemental Security Income)? Now SSI recipients may qualify for CalFresh Food*
- Yes
- No
Applicant's Name*
Applicant's City*
Applicant's Zip Code*
Applicant's Email
Applicant's Phone*
Best time for applicant to be reached*
- Morning (before noon)
- Afternoon (noon - 5pm)
- No Preference
Additional Information / Notes Regarding Applicant
Comments
This field is for validation purposes and should be left unchanged.