January 6, 2013

Program Guide Letter #592



Revised CalFresh Application Form (CF 285)


Effective Date

Upon Receipt



All County Letter (ACL) 13-75 and CalFresh Program Memo No. 13-04



·         To issue instructions regarding the revised streamlined CalFresh application form (CF 285);

·         Guidance for obsoleting several supplemental CalFresh forms;

·         Sunset date and destruction of the former application forms DFA 285 A1, DFA 285 A2 and DFA 285 A3.



The California Department of Social Services (CDSS) CalFresh Branch began the process of revising its application forms in January 2013 with the guidance of a workgroup consisting of key stakeholders (counties, consortia representatives, and advocates).  In developing the new application, the workgroup reviewed several other state applications for ideas.


Summary of Changes to the Application

·         Replaces the three current DFA application forms with one ten page form which combines the application, statement of facts and rights and responsibilities forms;

·         The “Coversheet” and “Program Rules and Penalties” (Rights & Responsibilities) section was simplified and moved to the beginning of the application enabling the applicant to tear off those pages and keep them for their records;

·         The “County Use Section” was deleted from the application with the exception of the Expedited Services (ES) section;

·         A question was added that asks the applicant if they are interested in applying for Medi-Cal and, if they answer yes, that the information captured on the CalFresh application will be shared to assist in the eligibility determination for Medi-Cal (see Medi-Cal impact below);

·         A  question was added which asks the applicant if they wish to get notices about their case by e-mail (this feature is currently not available; however a future Program Guide Letter will offer instructions regarding implementation of this option in San Diego County);

·         The CalFresh Supplemental Application for Special Medical Deductions (DFA 285-C) and CalFresh Program Qualifying Drug Felon Addendum (FS 26) forms were added into the new application;

·         Includes a question regarding interview preference times in order to best reach the applicant to conduct a telephone interview.


Signature Page

The revised CalFresh application will require only one signature.

Once a signed CF 285 or SAWS 2 Plus is received, staff will no longer be required to mail the application forms to the household for additional signature(s) after conducting a telephone interview.  Once a telephone interview is conducted staff no longer have to wait for the household to return the application forms in order to determine eligibility and issue timely benefits.  Staff will still provide the CalWIN electronic SAWS 2 Plus to the customer to review once the interview is completed to ensure the correct information was entered.  

If the customer comes to the Family Resource Center (FRC) to apply for CalFresh and is given a telephone appointment for a future date, the CF 285 should be provided to allow for the convenience of the customer in supplying one application without having to return additional forms.

The signature page is located on the first page of the application and will capture the application filing date, applicant’s name, address, and signature allowing households to file a partially completed application as indicated in 63-103.8.  Prior to submitting the application, staff may encourage applicants to complete as much as possible to better support the determination and benefit issuance process.


A partially completed application containing the applicant’s name, address, and signature is considered filed, even if the household has not been interviewed prior to submitting the application (63-103.8).  Staff shall not require an individual to complete an entire application prior to filing.


Expedited Services (ES)

As previously reinforced in CFPG Letter #582, staff is required to screen all CalFresh applications to determine if applicants meet the criteria for Expedited Services (ES).  The screening for ES may be documented using the screening tool on the new CF 285.  Staff is not required to use the screening tool, but must still document in case comments that the application was screened for ES entitlement and the result of the screening.

Staff will process the application under the three day ES timeframe if:

1.    The applicant checked the “Yes” box for any of the ES criteria questions under Question 1 of the CF 285; or

2.    The applicant provided sufficient information in answering the questions relevant to making a determination of ES entitlement on the CF 285.

If the above criteria are not met then the application is to be processed under the normal 30 day processing timeframe.


If after the ES was reviewed and determined no entitlement (denied in CalWIN) and the worker later discovers that the household is now entitled to ES on a pending case ES shall be reevaluated within the ES timeframes.  The exception is that day zero is the date the worker discovers the household’s entitlement to ES or the day the applicant requests an ES evaluation.


Other Applications and Rights & Responsibilities

In general the CF 285 should be used for all non-assistance CalFresh applications.  However, in the event that a SAWS 1 is accepted for CalFresh, the Rights and Responsibilities pages of the CF 285 (pages 1 of 4, 2 of 4 and 3 of 4) must be reviewed with the customer and provided to them.  FRCs may wish to have additional copies of the Rights and Responsibilities available for interactive interviews until CalWIN is updated with the new application.  Staff must continue to document in case comments that the rights and responsibilities were reviewed with the applicant, provided to them and that the applicant stated they understood the information.

·         If the customer is applying for multiple programs (e.g. CalWORKs, Public Assistance CalFresh (PACF) and Medi-Cal) then the SAWS 2 Plus Application for CalFresh, Cash Aid, and/or Medi-Cal should be used.


Program Guide Updates




·         Added the CF 285 and the SAWS 2 PLUS to the list of acceptable application forms

·         Removed reference to the DFA 285 A1, A2 and A3 forms

·         Included highlights of how the CF 285 is to be used


·         Added CF 285 and removed reference to the DFA A1, A2 and A3 forms

·         Replaced the FS 23 QR with the CF 23 SAR and CF 23 CR

·         Removed 09-83


Replaced DFA forms with CF 285 and SAWS 2 PLUS


Added an example of an inappropriate withdrawal


Removed section as it is no longer relevant to current business processes


Replaced DFA forms with CF 285 and SAWS 2 PLUS


Replaced DFA forms with CF 285 and SAWS 2 PLUS


Added information that applicants are not required to sign and return application forms after a telephone interview is conducted


Removed information regarding mailing time as it no longer applies to the revised applications


Updated to reflect retroactive recertifications


·         Updated forms

·         Included procedures for use of the SAWS 1


Removed information regarding the Face-To-Face Waiver Special Indicators as this is no longer required


Added that a signed application is not required to be to be returned for review after the telephone interview


Updated forms


Removed reference to the 09-83


Updated forms


·         Removed reference to reporting School Enrollment at periodic reporting and when voluntary reported per clarification from the CDSS

·         Updated forms and question numbers


Updated forms and instructions on FS 26


Updated required forms for recertification packets


Replaced Quarterly Reporting instructions with recertification under Semi-Annual Reporting


Removed references to Quarterly Reporting

63-304.8 - 63-304.16

·         Updated QR With SAR

·         Changed Benefits CalWIN to My Benefits CalWIN (BCW to MBC)

·         Replaced FRC OA with DPC OA


Updated forms


Updated forms


Updated forms


Updated and added forms



Forms Impact

The following forms are now obsolete:

·         FS 22 QR

·         TEMP 2215

·         FS 27

Remaining copies of the following forms must be destroyed no later than January 1, 2014:

·         DFA 285-A1

·         DFA 285-A2

·         DFA 285-A3

Staff shall continue to accept a DFA 285-A1 as an application for CalFresh should one be filed. 

The SAWS 2 Plus contains the same information as found on the CF 285 and is therefore an acceptable application for CalFresh benefits.  A revised SAWS 1 will be released by CDSS shortly along with further instructions regarding the SAWS 2 Plus.  Until the SAWS 2 Plus is available in CalWIN, staff may use the CSF 67 in instances when the CF 285 or SAWS 2 Plus was not used (e.g. when the SAWS 1 and CalWIN CSF 60 were used in lieu of the CF 285).

The FS 27/CF 27 is no longer approved for use as it was designed to be used in conjunction with a status report at recertification.  Under Semi-Annual Reporting (SAR) a status report is only required at six months and not at recertification.  The Supplemental Application for Special Medical Deductions (DFA 285-C) and CalFresh can be used for adding a new household member who is elderly or disabled with out of pocket medical expenses. 

The Spanish CF 285 translation is currently available through the Xerox Print Center.  The CDSS is working to provide other translations of the form.


Automation Impact

The SAWS 2 Plus is anticipated to be integrated into CalWIN with Release 35B scheduled for 12/30/13.


Other Programs Impact


Staff may use the SAWS 1 until further notice as a CalFresh application in the Medi-Cal packets as indicated in MPG Article 4 Section 2.2(C) and Aricle 4 Section 15.3.B.


Upon the return of a CF 285, if the applicant indicates that they are interested in applying for Medi-Cal, the information captured on the CalFresh application will be shared to assist in the completion of an eligibility determination for Medi-Cal.  If there is no active or pending Medi-Cal, the Human Services Specialist (HSS) reviewing the application in the FRC will mail the TEMP 14-22 HHSA Request for Tax Household Information (RFTHI) to the household.  The Medi-Cal Beginning Date of Aid (BDOA) will be established upon receipt of the RFTHI.


Quality Control Impact

Quality Control (QC) will cite the appropriate error when instructions in this material are not followed or are followed incorrectly.


Director Approval

Rick Wanne, MA, MFT

Eligibility Operations Director