Social Services Agency Food Stamp Recertification

Transcripción

County of Orange
Bid 017-976001-GH
Solicitation 017-976001-GH
Social Services Agency Food Stamp Recertification Packets
Bid designation: Public
County of Orange
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County of Orange
Bid 017-976001-GH
Bid 017-976001-GH
Bid Number
Bid Title
017-976001-GH
Bid Start Date
Bid End Date
Nov 18, 2013 8:06:56 AM PST
Nov 20, 2013 1:00:00 PM PST
Question & Answer
End Date
Nov 19, 2013 12:00:00 PM PST
Bid Contact
Gloria C Horton
Deputy Purchasing Agent-Buyer I
714-834-6884
[email protected]
Contract Duration
Contract Renewal
One Time Purchase
Not Applicable
Prices Good for
Not Applicable
Standard Disclaimer
The County of Orange is not responsible for and accepts no liability for any technical difficulties
or failures that result from conducting business electronically.
Bid Comments
THE COUNTY OF ORANGE, COUNTY EXECUTIVE OFFICE - INFORMATION TECHNOLOGY (CEO-IT)/PUBLISHING
SERVICES DEPARTMENT IS SOLICITING BIDS FOR A ONE-TIME PURCHASE AND DELIVERY CONTRACT FOR
PRINTING AND BINDERY OF THREE SOCIAL SERVICES AGENCY FOOD STAMP RECERTIFICATION PACKETS:
PROJECT #1. FOOD STAMP RECERTIFICATION PACKET (ENGLISH VERSION)
PROJECT #2. FOOD STAMP RECERTIFICATION PACKET (SPANISH VERSION)
PROJECT #3. FOOD STAMP RECERTIFICATION PACKET (VIETNAMESE VERSION)
BASIS OF AWARD: ALL OR NONE
PLEASE SEE ATTACHED PRINTING SPECIFICATIONS (ATTACHMENT A) FOR DETAIL PROJECT INFORMATION.
ALL QUESTIONS PERTAINING TO THIS INVITATION FOR BID (IFB) MUST BE SUBMITTED THROUGH BIDSYNC; ANY
COUNTY RESPONSE RELEVANT TO THIS IFB OTHER THAN THROUGH OR APPROVED BY CEO-IT/PURCHASING
DIVISION IS UNAUTHORIZED AND WILL BE CONSIDERED INVALID.
ALL BID RESPONSES SHALL BE SUBMITTED THROUGH BIDSYNC AND THE FOLLOWING MUST BE COMPLETED IN
ORDER FOR BID TO BE VALID:
1. COUNTY OF ORANGE COVER SHEET
2. SIGNATURE PAGE
3. COMPANY PROFILE
4. REFERENCES
5. CHILD SUPPORT ENFORCEMENT WEB FORM
6. BIDSYNC PRICING
ALL THREE PROJECTS MUST BE DELIVERED ON OR BEFORE DECEMBER 16, 2013, 3:30 PM (PST), TO PUBLISHING
SERVICES AT THE ADDRESS LISTED BELOW:
COUNTY OF ORANGE
CEO-IT/PUBLISHING SERVICES
ATTN: TBD
1300 S. GRAND AVE., BLDG. A
SANTA ANA, CA 92705
REFERENCE #: P1055787 - FSR PACKET ENGLISH/P1055788 - FSR PACKET SPANISH/P1055789 - FSR
PACKET VIETNAMESE
THE WINNING VENDOR SHALL PROVIDE ELECTRONIC PROOFS TO THE COUNTY.
THE COUNTY WILL ACCEPT DELIVERY OF ALL THREE PACKETS ON SEPARATE DAYS AS LONG AS THEY ARE ALL
DELIVERED BY DECEMBER 16, 2013, 3:30 PM (PST).
Item Response Form
Item
017-976001-GH--01-01 - FOOD STAMP RECERTIFICATION PACKET (ENGLISH VERSION)
Quantity
15925 set
Unit Price
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County of Orange
Delivery Location
Bid 017-976001-GH
County of Orange
025 - PUBLISHING SERVICES/PAPER
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
Qty 15925
Description
FOOD STAMP RECERTIFICATION PACKET (ENGLISH VERSION)
Item
017-976001-GH--01-02 - FOOD STAMP RECERTIFICATION PACKET (SPANISH VERSION)
Quantity
8925 set
Unit Price
Delivery Location
County of Orange
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
Qty 8925
Description
FOOD STAMP RECERTIFICATION PACKET (SPANISH VERSION)
Item
017-976001-GH--01-03 - FOOD STAMP RECERTIFICATION PACKET (VIETNAMESE VERSION)
Quantity
3350 set
Unit Price
Delivery Location
County of Orange
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
Qty 3350
Description
FOOD STAMP RECERTIFICATION PACKET (VIETNAMESE VERSION)
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County of Orange
Bid 017-976001-GH
County of Orange ± Bidder Instructions
1. DEFINITIONS:
a. "Bid" means an offer, made in response to a solicitation to perform a contract for work and labor or to supply goods or services at a
specified price, whether or not it is considered a "sealed bid" or results in award of a contract to a single or non-competitively bid contract.
b. "Bidder" means a supplier who submits a bid to the County in response to a solicitation.
c. "Solicitation" means the process, by whatever name known or in whatever format used, of notifying prospective bidders that the County
wishes to receive bids for furnishing goods or services.
d. "Supplier" means a business entity, bidder, offeror, vendor or contractor.
e. "County" means the County of Orange.
2. SUBMISSION OF BIDS:
a. Bids must be hand delivered or sent via U.S. Mail or common carrier unless another method is specifically authorized in the solicitation.
b. Where a "sealed" bid is required, each bid shall be separately sealed inside an envelope and must be signed and received by the closing
time and date specified, and on the forms furnished by the County to be considered for award.
c. The bidder is solely responsible for ensuring that the full bid is received by the County in accordance with the solicitation requirements,
prior to the date and time specified in the solicitation, and at the place specified. The County shall not be responsible for any delays in mail
or by common carriers or by transmission errors or delays or misdelivery.
d. Bids received after the bid closing date and time will be considered nonresponsive.
e. If no time for receipt of bids is specified in the solicitation, the bid shall be due by the close of the business day on the date indicated. Close
of the business day shall be 5:00 p.m. All times are Pacific Standard Time (PST).
f. Generally, sealed bids will be opened and read on the due date unless another date and time is specified in the solicitation or any
addendum thereto or the reverse auction terms and conditions are included in the solicitation. When a County Agency/Department
facilitates a reverse auction, all bids shall remain confidential before and during the auction. Information is not public, including the number
and names of the responders, until the Notice of Intent to Award or contract award is published, whichever occurs first.
g. Faxed bid responses will NOT be allowed.
h. All bids received by the County and opened are subject to disclosure under the California Public Records Act, and other applicable law.
i. It is preferred that bids/proposals be submitted electronically at www.bidsync.com , unless otherwise stated in the bid packet. If responding
to this solicitation through BidSync, the electronic version of the bid response will prevail. The County of Orange is not responsible for and
accepts no liability for any technical problems that result from conducting business electronically.
j. The County shall not be liable for any expenses incurred by potential Bidders in the preparation or submission of their bids. The County
shall not, in an event, be liable for any pre-contractual expenses incurred by Bidders prior to the date of award and execution, if any, of
the Contract. Pre-contractual expenses are defined as expenses incurred by the Bidder in: a) preparing its bid in response to this IFB; b)
submitting that bid to the County; c) negotiating with the County any matter related to the Bidder's bid; and d) any other expenses incurred
by the Bidder prior to the date of award and execution, if any, of the Contract.
k. Bids are not to be marked as confidential or proprietary. The County shall refuse to consider any bid so marked. Additionally, all bids shall
become the property of the County. The County reserves the right to make use of any information or ideas in the bids submitted.
l. If clarification of this IFB is considered necessary, a written addendum shall be issued. Oral statement(s) concerning the meaning of the
contents of this IFB by County personnel or any other person is (are) unauthorized and should not be relied upon. All inquiries concerning
this IFB should be directed to the assigned DPA (Deputy Purchasing Agent) per the instructions in the IFB.
m. Bidders shall be solely responsible for any errors or omissions in their bids. Any discrepancies in numbers or calculations shall be
interpreted to reflect the lowest price to the County .
n. The Model Contract contained in this solicitation is the Contract proposed for execution. Negotiations may or may not be conducted with the
finalists; therefore, the response submitted should contain Offeror's most favorable terms and conditions, since the selection and award
may be made without further discussion. Any exceptions to the terms and conditions made by any Offeror after submission of its
response may result in elimination from further consideration .
o. Any exceptions to the County's terms and conditions must be clearly stated in responses to this solicitation. Any exception must include
the details of the exception and the reasons for it. The County reserves the right to disqualify vendors taking exception to its terms and
conditions. Vendors taking exception after notice of award will be disqualified from award of contract.
3. SOLICITATION ADDENDUM (ADDENDA):
a. The County of Orange does not guarantee that you will receive the addenda to this solicitation unless you received notification of this
solicitation by e-mail from BidSync on behalf of the County of Orange. Bidders registered on BidSync will receive an email notification
when an addendum has been created. A link to the County of Orange's online bidding web site can be found at:
http://egov.ocgov.com/ocgov/Procurement/Open%20Bids.
It is the Bidder's responsibility to request all additional information and/or modifications to this solicitation.
b. In the event that the solicitation is revised by an addendum, supplier shall submit the original solicitation and any addenda that the buyer
requires to be submitted.
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Bid 017-976001-GH
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c. Price(s) offered shall reflect all addenda issued by the County. Failure to do so will permit the County to interpret the bid to include all
addenda issued in any resulting contract.
4. PRICES:
a. All prices and notations must be typewritten.
b. All prices must be bid in U.S. currency.
c. Unit prices may not be more than four (4) places to the right of the decimal point. For example, a unit price of $.56726 each would exceed
this limitation. Unit prices which exceed this limitation will automatically be truncated to the fourth decimal place for both evaluation and
award purposes. Using the example just cited, the "6" at the end of the unit price would be truncated (i.e., dropped off) leaving a unit price
of $.5672 each.
d. An error in the bid may cause the rejection of that bid; however, the County may at its sole option retain the bid and make certain arithmetic
corrections. In determining if a correction will be made, the County will consider the conformance of the bid to the format and content
required by the solicitation, and any unusual complexity of the format and content required by the solicitation.
i. If the bidder's intent is clearly established based on review of the complete bid submittal, the County may at its sole option correct an
error based on that established intent.
ii. The County may at its sole option correct obvious clerical errors.
iii. The total price of unit-price items will be the product of the unit price and the quantity of the item. If the unit price is ambiguous,
unintelligible or uncertain for any cause, or is omitted, it shall be the amount obtained by dividing the "Extension" price by the quantity of
the item.
iv. Out of state contractors must include California Sales Tax permit number.
v. Prices quoted shall be firm for the first period of the price agreement.
vi. Cost increases may be considered during Contract renewal periods only. The County requires bona fide proof of cost increases prior
to any price escalation adjustment. A minimum of 30 (thirty) days advance notice in writing is required to secure such adjustments.
When offering escalating price bids, quote applicable labor and material separately as to percentage of total cost. No retroactive
pricing adjustments will be considered. The County may enforce, adjust, or cancel escalating price agreements as it sees fit. The net
dollar amount of profit will remain firm during the period of the price agreement. Adjustments increasing Contractor's profit will not be
allowed.
vii. All decreases will be automatically extended to the County
5. CASH DISCOUNTS: The County encourages bidders to offer cash discounts for prompt payment etc.; however, unless provided elsewhere in
the solicitation, cash discounts offered by bidders for the prompt payment of invoices will not be considered in evaluating offers to determine
the successful bidder for award of any resulting contract.
6. INSPECTION OF SOLICITATION DOCUMENTS: Supplier shall carefully review all documents referenced and made a part of this solicitation to
ensure that all information required to properly respond to the solicitation has been received or made available and all requirements are priced
in the bid. Failure to examine any document, drawing, specification, or instruction will be at the supplier's sole risk.
7. BRAND NAMES: Any reference to brand names and/or numbers in the solicitation is intended to be descriptive, but not restrictive, unless
otherwise specified. Bids offering equivalent items meeting the standards of quality specified may be considered, unless otherwise specified,
providing the bid clearly describes the article offered and how it differs from the referenced brand. Unless bidder specifies otherwise, it is
understood that the bidder is offering a referenced brand item as specified in the solicitation. The County reserves the right to determine
whether a substitute offer is equivalent to and meets the standards of quality indicated by the brand name references, and the County may
require the supply of additional descriptive material and a sample.
8. EVALUATION OF BIDS:
a. Where more than one line item is specified in the solicitation, the County reserves the right to determine the lowest, responsive and
responsible bidder, either on the basis of individual items, combination of items as specified in the solicitation, or on the basis of all items
included in the solicitation, unless otherwise expressly provided.
b. Unless otherwise specified in the solicitation, the County may accept any item or combination of items as specified in the solicitation, of any
bid unless the bidder expressly objects and conditions its response on receiving all items for which it provided a bid. In the event that the
bidder so objects, the County may consider the bidder's objection and evaluate whether the award on such basis will result in the lowest
price to the County or may determine in its sole discretion that such an objection is non-responsive and renders the bidder ineligible for
award.
c. All other criteria to be used in evaluating bids will be identified elsewhere in the solicitation.
9. CONFLICT OF INTEREST:
a. Current County Employees (PCC Section 10410):
i. No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives
compensation or has a financial interest and which is sponsored or funded by any County Agency/Department, unless the
employment, activity or enterprise is required as a condition of regular County employment.
ii. No officer or employee shall contract on his or her own behalf as an independent contractor with any County agency to provide goods
or services.
b. Former County Employees (PCC Section 10411): For the two-year period from the date he or she left County employment, no former County
officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements
or any part of the decision-making process relevant to the contract while employed in any capacity by any County agency/department.
c. For the twelve-month period from the date he or she left County employment, no former County officer or employee may enter into a
contract with any County agency/department if he or she was employed by that County agency in a policy-making position in the same
general subject area as the proposed contract within the twelve-month period prior to his or her leaving County service.
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County of Orange
Bid 017-976001-GH
10. JOINT BIDS: Where two or more Suppliers desire to submit a single bid in response to a solicitation, they should do so on a
prime/subcontractor basis rather than as a joint venture. The County intends to contract with a single firm or multiple firms, but not with
multiple firms doing business as a joint venture.
11. SAMPLES TO DETERMINE RESPONSIVENESS TO TECHNICAL REQUIREMENTS FOR PURPOSES OF AWARD:
a. Samples of items, when required by the County, must be furnished free of expense to the County, unless otherwise provided.
b. Unless expressly set forth in the solicitation, the sample or samples furnished must be identical in all respects to the product or products
being offered to the County.
c. Bidders offering products of a different manufacturer and model number than those specified in the solicitation may be required to submit
samples for inspection and specification compliance testing in order for the County to determine if the item offered is equivalent to and
meets the minimum standards of quality acceptable to the County as indicated by the manufacturer and model number specified in the
solicitation.
d. Samples, if not destroyed by tests, may, upon request made at the time the sample is furnished, be returned at bidder's expense.
e. Samples may be required prior to award. If requested, such samples must be delivered to the address specified and within the timeframe
identified in the notification. Failure to submit samples as specified may be grounds for rejection.
12. SPECIFICATION CONCERNS:
a. In the event a supplier believes that the County's solicitation is unfairly restrictive, ambiguous, contains conflicting provisions or mistakes or
in the supplier's experience any resulting contract would be commercially impractical to perform, the matter should be promptly brought to
the attention of the buyer identified in the solicitation, in writing, immediately upon receipt of the solicitation, in order that the matter may be
fully considered and appropriate action taken by the County prior to the closing time set to receive bids.
13. VALIDITY OF BID: Unless specified elsewhere in the
solicitation, bidder's bid shall be valid for a minimum of one hundred eighty (180) days following the bid closing date.
14. MISTAKE IN BID: If prior to contract award, a bidder discovers a mistake in their bid which renders the bidder unwilling to perform under any
resulting contract, the bidder must immediately notify the buyer and request to withdraw the bid. It shall be solely within the County's
discretion as to whether withdrawal will be permitted. If the solicitation contemplated evaluation and award of "all or none" of the items, then
any withdrawal must be for the entire bid. If the solicitation provided for evaluation and award on a line item or combination of items basis, the
County may consider permitting withdrawal of specific line item(s) or combination of items.
15. COUNTY'S RIGHTS:
a. The County reserves the right to modify or cancel in whole or in part its solicitation at any time without prior notice.
b. The County reserves the right to reject any or all bids if the County determines that a bidder's bid was non-responsive to the solicitation
requirements and to waive informalities and minor irregularities in bids received.
c. The County reserves the right to reject any or all bids if the County determines that a bidder is not a responsible supplier.
d. Award final Contract with the lowest, responsive, responsible Bidder or Bidders as necessary to serve the best interests of the County
may require.
e. Award its total requirement to one Bidder or to apportion those requirements among two or more Bidders as the County may deem to be in
its best interests.
f. Make no guarantee as to the usage of the services by the County. The County furthermore makes no representation that any Contract will
be awarded to any Bidder responding to this IFB.'
g. All bids received may be public record after opening. Bids are not to be marked as confidential or proprietary. The County shall refuse to
consider any bid so marked. Bids must be submitted in response to this IFB may be subject to public disclosure as permitted by the
California Public Records Act. Additionally, all bids shall become the property of the County. The County reserves the right to make use of
any information or ideas in the bids submitted.
h. Waive, at its discretion, any irregularity or informality which the County deems correctable or otherwise not warranting rejection of the bid.
i. Make final award determination based on the lowest responsive, responsible bid, but award will be contingent upon agency/department
approval, including a review of qualifications, and the successful bidder must have met all the qualifications/requirements set forth herein.
16. UNFAIR PRACTICES ACT AND OTHER LAWS: Supplier warrants that its bid complies with the Unfair Practices Act (Business and
Professions Code Section 17000 et seq.) and all applicable County, State and Federal laws and regulations.
17. VIOLATION OF AIR OR WATER POLLUTION LAWS:
a. Prior to an award, the County shall ascertain if the intended awardee is a person included in notices from the Boards. In the event of any
doubt of the intended awardees' identity or status as a person who is in violation of any County, State, or federal air or water pollution
law, the County will notify the appropriate Board of the proposed award and afford the Board the opportunity to advise the County that the
intended awardee is such a person.
b. No award will be made to a person who is identified either by the published notices or by advice, as a person in violation of County, State,
or federal air or water pollution control laws.
18. INDEPENDENCE OF BID: By submitting this bid, bidder swears under penalty of perjury that it did not conspire with any other supplier to set
prices in violation of anti-trust laws.
19. PROTESTS: All protests shall be submitted on protester's letterhead and include at minimum the following information:



The name, address and telephone number of the protester;
The signature of the protester or the protester's representative;
The solicitation or contract number;
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Bid 017-976001-GH
 A detailed statement of the legal and/or factual grounds for the protest; and
 The form of relief requested
All protests related to bid or proposal specifications must be submitted to the Deputy Purchasing Agent no later than five (5) business days
prior to the close of the bid or proposal. Protests received after the five (5) business day deadline will not be considered by the County. In the
event the protest of specifications is denied and the protester wishes to continue in the solicitation process, they must still submit a bid prior to
the close of the solicitation in accordance with the bid/proposal submittal procedures provided in the bid/proposal.
In protests related to the award of a contract , the protest must be submitted no later than five (5) business days after the notice of the
proposed contract award is provided by the Deputy Purchasing Agent. Protests relating to a proposed contract award which are received
after the five (5) business day deadline will not be considered by the County.
If the protester wishes to appeal the decision of the Deputy Purchasing Agent, the protester must submit, within three (3) business days from
receipt of the Deputy Purchasing Agent's decision, a written appeal to the Office of the County Purchasing Agent at:
1300 S. Grand Ave., Bldg A Santa Ana, CA 92705
The decision of the County Purchasing Agent on whether to allow the appeal to go forward will be final and there shall be no right to any
administrative appeals of this decision.
20. INDEPENDENT CONTRACTOR REPORTING REQUIREMENTS: Any independent contractor, prior to being awarded a purchase order which
contains services, must provide certain information pertaining to its business to the County. The County, in accordance with Unemployment
Insurance Code Section 1088.8, will report such information to the Employment Development Department. By submitting a bid, bidder
acknowledges this information is required and that it is being reported to the Employment Development Department.
Additional information on this reporting requirement can be found at the California Employment Development Department web site located at
www.edd.ca.gov/txicr.htm .
21. Orange County Child Support: To comply with the child support enforcement requirements of the County of Orange, within ten days of
notification of selection of award of contract but prior to official award of contract, the selected contractor agrees to furnish to the contract
administrator, the Purchasing Agent, or the agency/department deputy purchasing agent:
a. In the case of an individual contractor, his/her name, date of birth, Social Security number, and residence address;
b. In the case of a contractor doing business in a form other than as an individual, the name, date of birth, Social Security number, and
residence address of each individual who owns an interest of ten (10) percent or more in the contracting entity;
c. A certification that the contractor has fully complied with all applicable federal and state reporting requirements regarding its employees;
and
d. A certification that the contractor has fully complied with all lawfully served Wage and Earnings Assignment Orders and Notices of
Assignment and will continue to so comply.
Failure of the contractor to timely submit the data and/or certifications required may result in the contract being awarded to another
contractor. In the event a contract has been issued, failure of the contractor to comply with all federal, state, and local reporting requirements
for child support enforcement or to comply with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignment shall
constitute a material breach of the contract. Failure to cure such breach within 60 calendar days of notice from the County shall constitute
grounds for termination of the contract.
22. AMERICANS WITH DISABILITY ACT (ADA): To comply with the non-discrimination requirements of the ADA, it is the policy of the County to
make every effort to ensure that its programs, activities and services are available to all persons, including persons with disabilities. For
persons with a disability needing a reasonable modification to participate in the procurement process, or for persons having questions
regarding reasonable modifications for the procurement process, you may contact the buyer listed in the solicitation.
23. Vendor Advisory: The County does not require and neither encourages nor discourages the use of lobbyists or other consultants for the
purpose of securing business.
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http://egov
.ocgov.co
m/vgnfiles/
ocgov/OC
GOVPortal/
Branding/a
COUNTY OF ORANGE
DEPT
SOLICITATION NUMBER:
-976001 -GH
FOR:
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Bid 017-976001-GH
Signature Page
I have read and understand and agree to the terms and conditions herewith and I am submitting a
response to this solicitation .
Date:
Company Name:
* Authorized Signature
Print Name
Title
Print Name
Title
OR
I prefer not to submit a bid in response to this solicitation per the reason(s) given below.
Reason(s):
aaa
Date:
Company
Name:
Print Name
Title
* If the Contractor is a corporation, signatures of two specific corporate officers are required as further
set forth.
The first corporate officer signature must be one of the following:1) the Chairman of the Board; 2) the
President; 3) any Vice President.
The second corporate officer signature must be one of the following: a) Secretary; b) Assistant
Secretary; c) Chief Financial Officer; d) Assistant Treasurer.
In the alternative, a single corporate signature is acceptable when accompanied by a corporate
resolution demonstrating the legal authority of the signature to bind the company.
RETURN THIS SHEET WITH YOUR RESPONSE
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Bid 017-976001-GH
Part 2:
Company Profile
(Complete this form and submit as Part 2 in second tabbed section of response)
Company Legal Name:
Business Address:
Address for mailed funds:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
Length of time the firm has been in business:
Length of time at current location:
Is your firm a sole proprietor doing business under a different name:
Yes
No
If yes, please indicate sole proprietor's name and the name you are doing business under:
Federal Taxpayer ID Number
Is your firm incorporated:
Yes
No
State of Incorporation:
Regular business hours:
Regular holidays and hours when business is closed:
Contact person in reference to this request for RFP solicitation:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
Name of administrator to who questions regarding accounts payable should be directed:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
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County of Orange
Bid 017-976001-GH
EXHIBIT B
References
All Bidders must provide a minimum of three (3) Letters of Reference. The references should be from clients who
are comparable in scope to the County of Orange. Include one reference from a governmental agency. References
must cover services performed by your company in the past five (5) years. At least one of the references must cover
services performed in the past year. Services should be similar to those services required in this solicitation.
Additionally, please complete the form below on the clients who have provided references:
References must include the name and address of the company or governmental agency and the name and telephone
and facsimile numbers of contact person(s), annual agreement dollar amount of the Contract, and a brief description of
the agreement/Contract work and services provided. Attach additional sheets if necessary.
1.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Annual agreement dollar amount:
Facsimile Number:
Brief Description of agreement/Contract work or services provided:


2.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Facsimile Number:


3.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Facsimile Number:


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Bid 017-976001-GH
County of Orange Child Support Enforcement
Certification Requirements
(blank form)
A.
In the case of an individual Contractor, his/her name, date of birth, Social Security number, and residence address:
Name:
D.O.B:
Social Security No:
Residence Address:
B.
In the case of a Contractor doing business in a form other than as an individual, the name, date of birth, Social
Security number, and residence address of each individual who owns an interest of ten (10) percent or more in the
contracting entity:
Name:
D.O.B:
Social Security No:
Residence Address:
Name:
D.O.B:
Social Security No:
Residence Address:
Name:
D.O.B:
Social Security No:
Residence Address:
(Additional sheets may be used if necessary)
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Bid 017-976001-GH
C.
A certification that the Contractor has fully complied with all applicable federal and state reporting requirements
regarding its employees; and
D.
A certification that the Contractor has fully complied with all lawfully served Wage and Earnings Assignment
Orders and Notices of Assignment and will continue to so comply.
"I certify that
is in full compliance with all
applicable federal and state reporting requirements regarding its employees and with all lawfully served
Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance
throughout the term of Contract
with the County of
Orange. I understand that failure to comply shall constitute a material breach of the Contract and that
failure to cure such breach within ten (10) calendar days of notice from the County shall constitute
grounds for termination of the Contract.
Authorized Signature
11/19/2013 11:22 AM
Print Name
Title
p. 13
County of Orange
Bid 017-976001-GH
ATTACHMENT A
SCOPE OF WORK
I.
THIS IS A ONE-TIME PURCHASE FOR THE PRINTING AND DELIVERY OF THREE SOCIAL
SERVICES AGENCY FOOD STAMP RECERTIFICATION PACKETS AS LISTED:
1. PROJECT #1. FOOD STAMP RECERTIFICATION PACKETS (ENGLISH VERSION) – 15,925 SETS
2. PROJECT #2. FOOD STAMP RECERTIFICATION PACKETS (SPANISH VERSION) – 8,925 SETS
3. PROJECT #3. FOOD STAMP RECERTIFICATION PACKETS (VIETNAMESE VERSION) - 3,350
SETS
II.
ALL THREE PROJECTS MUST BE DELIVERED TO PUBLISHING SERVICES DEPARTMENT ON OR
BEFORE DECEMBER 16, 2013, 3:30 P.M. (PACIFIC STANDARD TIME) AT THE ADDRESS LISTED
BELOW:
CEO-IT/PUBLISHING SERVICES
1300 S. GRAND AVE. BLDG. A
SANTA ANA, CA 92705
REFERENCE: P1055787-FSR PACKET ENGLISH/P1055788-FSR PACKET SPANISH/P1055787
FSR PACKET VIETNAMESE P1055789
ATTN: TBD
PHONE: TBD
EMAIL: TBD
III.
COUNTY PROJECT CONTACT:
ATTN: TBD
PHONE: TBD
EMAIL: TBD
BLDG. A, 1st FLOOR
SANTA ANA, CA 92705
COUNTY PURCHASING CONTACT:
GLORIA HORTON
CEO/IT PURCHASING DIVISION
1501 E. ST. ANDREW PLACE
SANTA ANA, CA 92705
PHONE: 714- 834-6884
FAX: 714-560-4524
EMAIL: [email protected]
IV.
CONTRACTOR INFORMATION:
(TBD)
V.
DETAILED DESCRIPTION OF WORK TO BE PERFORMED BY CONTRACTOR AS LISTED UNDER
EACH PRINTING SPECIFICATION ATTACHMENT AND ALSO IN THIS SCOPE OF WORK :
1.
FILES FOR EACH PROJECT HAVE BEEN ATTACHED SEPARATE. PLEASE REVIEW FOR
MORE INFORMATION ON PRINTING DETAILS.
2.
VENDOR SHALL BE REPONSIBLE FOR THE PICK UP OF FORMS AND LABELS FROM
PUBLISHING SERVICES ADDRESS.
3.
CONTRACTOR WILL BE PROVIDED WITH SPECIAL BOX LABELS FOR EACH PRINTING
PROJECT.
11/19/2013 11:22 AM
p. 14
County of Orange
Bid 017-976001-GH
4.
NO UNDERRUNS ALLOWED.
5.
OVERRUNS WILL BE PAID IF APPROVED BY COUNTY OF ORANGE BUYER.
6.
COUNTY MUST RECEIVE ALL FOOD STAMP RECERTIFICATION PACKETS BY OR BEFORE
DECEMBER 16, 2013, 3:30 P.M. (PST).
7. ANY CHANGES OR CORRECTIONS MUST BE VERIFIED IN WRITING TO CONTRACTOR
BY PURCHASING.
8. FREIGHT MUST BE INCLUDED IN BID PRICE OR VENDOR MAY LIST AS ADDITIONAL
ITEM.
CONTRACTOR IS REQUIRED TO RETURN PRODUCED OR PROVIDED ARTWORK WITH
REVISION TO DEPARTMENT WITH COMPLETED JOB. FAILURE TO COMPLY COULD RESULT
IN DISQUALIFICATION AS A CONTRACTOR.
CEO/IT REGULAR BUSINESS HOURS ARE 8:00 A.M. TO 5:00 P.M. (PST), MONDAY THROUGH
FRIDAY.
11/19/2013 11:22 AM
p. 15
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 16
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 17
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 18
County of Orange
Bid 017-976001-GH
ATTACHMENT B
COMPENSATION AND PRICING PROVISIONS
This is a fixed fee Contract between the County and Contractor for goods and services provided in Attachment A, Scope
of Work. The Contractor agrees to accept the specified compensation as set forth in this Contract as full remuneration for
services.
1. Pricing
Pricing set forth in this Attachment shall be firm for the term of the Contract. All price decreases will automatically be
extended to the County of Orange. County will accept a decrease only. Pricing below will be firm unless a reduction is
available.
Description
FOOD STAMP
RECERTIFICATION
PACKET
(ENGLISH VERSION)
FOOD STAMP
RECERTIFICATION
PACKET
(SPANISH VERSION)
FOOD STAMP
RECERTIFICATION
PACKET
(VIETNAMESE VERSION)
Quantity
15,925
Unit
Sets
Unit Price
$ _______
Total Price
$_______
8,925
Sets
$_______
$_______
3,350
Sets
$_________
$_________
Subtotal
Sales Tax
Total Amount Due
$
$
$
2. Payment Terms
Contractor shall reference Contract number on invoice. Payment will be net 30 days after receipt of an invoice in a format
acceptable to the County of Orange and verified and approved by the agency/department and subject to routine processing
requirement. The responsibility for providing an acceptable invoice rests with Contractor.
Billing shall cover services and/or goods not previously invoiced. The Contractor shall reimburse the County of Orange
for any monies paid to the Contractor for goods or services not provided or when goods or services do not meet the
Contract requirements. Payments made by the County shall not preclude the right of the County from thereafter disputing
any items or services.
3. Invoicing Instructions:
Invoices and support documentation are to be sent to:
County of Orange
CEO/Information Technology
1501 E. St. Andrew Place, Suite 200
Santa Ana, CA 92705
Attn: Accounts Payable
Contractor will provide an invoice for services rendered, not more frequently than annually. Each invoice will have a
number and shall include the following information:
1.
2.
3.
4.
Contractor’s name and address
Contractor’s remittance address
County Contract number
Contractor’s Federal I.D. number
11/19/2013 11:22 AM
p. 19
County of Orange
5.
6.
7.
8.
Bid 017-976001-GH
Date of Order
Product/service description, quantity, prices
Sales tax, If applicable
Total invoice amount
The responsibility for providing an acceptable invoice to the County for payment rests with the Contractor. Incomplete or
incorrect invoices are not acceptable and shall be returned to the Contractor for correction.
11/19/2013 11:22 AM
p. 20
County of Orange
Bid 017-976001-GH
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11/19/2013 11:22 AM
p. 21
County of Orange
Bid 017-976001-GH
FOOD STAMP ANNUAL RECERTIFICATION APPOINTMENT LETTER
You were notified that your Food Stamp annual certification period is ending next month
and that you would receive an appointment to continue your benefits.
You have been scheduled for a telephone interview. A worker will be calling you at the
phone number you previously provided.
Please call the worker as soon as possible if:
x
The interview date or time is not convenient for you and you want to
reschedule.
x
You want the worker to call you at another contact number (such as a cell
phone or work phone).
x
You prefer to be interviewed in person and want to request an office
appointment.
Please complete, sign and date the enclosed required forms (Application for Food
Stamp Benefits/DFA 285-A1, Statement of Facts/DFA 285-A2, and Your Rights and
Responsibilities/DFA 285-A3 QR. Return them to us in the prepaid postage
envelope provided right away. The other materials provided are for your
information/records. We need to have your completed forms for review before we
complete/conduct your telephone interview. If we need any other papers from you,
we will tell you after we review your forms or during your telephone interview.
IMPORTANT REMINDERS
x
Failure to complete an interview will cause your Food Stamp benefits to stop.
x
If you cannot keep this scheduled appointment, it is your responsibility to reschedule it.
x
Your Quarterly Report QR7 is not required in the same month that your recertification
is scheduled. However, income verifications for all household members is required.
Please include them when you return these forms.
x
Any verification we need must be turned in within 10 days of our requesting it.
11/19/2013 11:22 AM
p. 22
County of Orange
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
Bid 017-976001-GH
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR CALFRESH BENEFITS
If you have a disability or need help with this application, let the County Welfare Department (County) know and
someone will help you.
If you prefer to speak, read, or write in a language other than English, the County will get someone to help you
at no cost to you.
How do I apply?
Use this application if you are applying for CalFresh benefits only. CalFresh is a food assistance program to help
you with the cost of buying food for your household. If you wish to apply for programs other than CalFresh such
as, CalWORKs or Medi-Cal, please ask for an application to apply for other programs. You can also apply for
CalFresh or other programs online by going to http://www.benefitscal.org/. You can see if you may be eligible by
going to http://www.cdss.ca.gov/foodstamps/PG849.htm.
• Fill out the whole application form, if you can. You must at least give the County your name, address, and
signature (question 1 on page 1) to begin the application process.
• Give the application to the County in person, by mail, by fax, or online.
• The day the County receives your signed application starts the time to give you an answer on whether you can
get benefits. If you are in an institution, this time starts from the day you leave.
What do I do next?
• Read about your rights and your responsibilities (Program Rules pages 1 through 3) before you sign the
application.
• You must have an interview with the County to discuss your application. Most interviews are done by phone,
but it can be done in person at the County office or other place arranged with the County. If you have a disability,
other arrangements can be made.
• If you did not fill out all of the application, you can finish it during your interview.
• You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.
How long will it take?
It may take up to 30 days to process your application. You may be able to get benefits within 3 calendar days, if:
• Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand
or in checking or savings accounts is $100 or less; or
• Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
cash on hand or in checking or savings accounts; or
• You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your
income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.
To help the County see if you can get benefits in three days, please answer questions 1, 6 through 8, 11, and 16,
and give the County proof of your identify (if you have it) with the application.
The County will send you a letter to let you know if your household is approved or denied CalFresh benefits.
Informational Page - Please take and keep for your records.
CF 285 (9/13)
11/19/2013 11:22 AM
COVERSHEET PAGE 1 OF 2
p. 23
County of Orange
Bid 017-976001-GH
What do I need for my interview?
To avoid delays, bring proof of the following with you to your interview. Keep your interview even if you do not
have the proof. The County may be able to help if you need help getting proof. During the interview, the County
will go over the information on the application and will ask you questions to see if you can get CalFresh benefits
and the amount of benefits you can get.
Proof Needed to Get Benefits
• Identification (Driver’s License, State ID card,
passport).
• Where you live (a rental agreement, current bill
with your address listed).
• Social Security Numbers (see note below about
certain noncitizens).
• Money in the bank for all the people in your
household (recent bank statements).
• Earned income of everyone in your household for
the past 30 days (recent pay stubs, a work
statement from an employer). NOTE: If selfemployed, income and expense or tax records.
• Unearned income (Unemployment benefits, SSI,
Social Security, Veteran’s benefits, child support,
worker’s compensation, school grants or loans,
rental income, etc.).
• Lawful immigration status ONLY for noncitizens
applying for benefits (an Alien Registration Card,
visa)
NOTE: Certain noncitizens applying for
immigration status based on domestic violence,
crime prosecution or trafficking may not need this
proof. They also may not need a Social Security
Number.
Proof Needed to Get More CalFresh Benefits
• Housing costs (rent receipts, mortgage bills,
property tax bill, insurance documents).
• Phone and utility costs.
• Medical expenses for anyone in your household
who is elderly (60 and older) or disabled.
• Child and adult care costs due to someone
working, looking for work, attending training or
school, or participating in a required work activity.
• Child support paid by a person in your
household.
How do I get/use my CalFresh benefits?
• The County will mail or give you a plastic Electronic Benefit Transfer (EBT) card. Benefits will be put on the
card when your application is approved. Sign your card when you get it. You will set up a Personal Identification
Number (PIN) to use your card.
• If your EBT card is lost, stolen, or destroyed, or you think someone may know your PIN number that you don’t
want to use your benefits call (877) 328-9677 or call the County right away. Make sure all responsible adults
and your authorized representative also know how to report one of these problems right away. If you do not
report that another person you do not want to spend your benefits has your PIN and you do not get your PIN
changed, any benefits used will not be replaced.
• You can use your CalFresh benefits to buy almost all foods, as well as seeds and plants to grow your own food.
You cannot buy alcohol, tobacco, pet food, some types of cooked food, or anything that is not food (like
toothpaste, soap, or paper towels).
• CalFresh benefits are accepted at most grocery stores and other places that sell food. For a list of locations
near you that accept EBT please go to: https://www.ebt.ca.gov or https://www.snapfresh.org.
• CalFresh benefits are only for you and your household members. Keep your benefits safe. Do not give out
your PIN number. Do not keep your PIN number with your EBT card.
What if I am homeless?
Please let the County know right away if you are homeless so they can help you figure out an address to use to
accept your application and get notices from the County regarding your case. For CalFresh, homeless means
you are:
A. Staying in a supervised shelter, halfway house, or similar place.
B. Staying at the home of another person or family for no more than 90 days straight.
C. Sleeping in a place not designed for, or normally used as, a place to sleep (e.g., a hallway, a bus station,
a lobby, or similar places).
CF 285 (9/13)
11/19/2013 11:22 AM
p. 24
County of Orange
Bid 017-976001-GH
RIGHTS AND RESPONSIBILITIES
You have a responsibility to:
•
•
•
•
•
•
Give the County all information needed to determine your eligibility.
Give the County proof of the information you have when it is needed.
Report changes as required. The County will give you information about what, when, and how to report. If
you don’t meet your household’s reporting requirements your case will be closed or your CalFresh benefits
may be lowered or stopped.
Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your
case.
Fully cooperate with County, State, or federal personnel if your case is selected for review or investigation to
ensure that your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will
result in loss of your benefits.
Pay back any CalFresh benefits that you were not eligible to get.
You have the right to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Turn in an application for CalFresh giving only your name, address, and signature.
Have an interpreter provided by the State at no cost if you need one.
Have information given to the County kept confidential, unless directly related to the administration of County
programs.
Withdraw your application at any time prior to the County determining eligibility.
Ask for help to fill out your application for CalFresh and get an explanation of the rules.
Ask for help to get proof that is needed.
Be treated with courtesy, consideration, and respect, and not be discriminated against.
Get CalFresh benefits within 3 days if you qualify for Expedited Service.
Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility
determined within 30 days.
Get at least 10 days to give the County proof that is needed to make a determination of eligibility.
Get written notice at least 10 days before the County lowers or stops your CalFresh benefits.
Discuss your case with the County and to review your case when you ask to do so.
Ask for a State hearing within 90 days if you do not agree with the County about your CalFresh case. If you
ask for a hearing before an action on your CalFresh case takes place, your CalFresh benefits will stay the
same until the hearing or the end of your certification period, whichever is earlier. You can ask the County to
let your benefits change until after the hearing to avoid having to pay back any over paid benefits. If the
Administrative Law Judge rules in your favor, the County will give back to you any benefits that were cut.
Ask about your hearing rights or for a legal aid referral at the toll-free phone number – 1-800-952-5253 or for
hearing or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal
aid or welfare rights office.
Bring a friend or someone with you to the hearing if you do not want to go alone.
Get assistance from the County to register to vote.
Report changes that you are not required to report, if it may increase your CalFresh benefits.
Give proof of your household’s expenses that may help you get more CalFresh benefits. Not giving proof to
the County is the same as saying that you do not have that expense and you will not be able to get more
CalFresh benefits.
Let the County know if you would like someone else to use your CalFresh benefits for your household or help
with your CalFresh case (Authorized Representative).
Please take and keep for your records
CF 285 (9/13)
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PROGRAM RULES PAGE 1 OF 4
p. 25
County of Orange
Bid 017-976001-GH
Program Rules and Penalties
You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get
CalFresh benefits that you are not eligible to receive, or to help someone else get benefits that they are not eligible to receive.
You must pay back any benefits you get that you were not eligible to receive.
I understand that if I...
Commit an intentional program violation by doing
any of the following:
I may...
•
hide information or make false statements
•
•
use electronic benefit transfer (EBT) cards that belong
to someone else or let someone else use my card
use CalFresh benefits to buy alcohol or tobacco
•
trade, sell, or give away CalFresh benefits or EBT
cards
•
•
trade CalFresh benefits for controlled substances,
such as drugs
•
•
•
give false information about who I am and where I live
so I can get extra CalFresh benefits
have been convicted of trading or selling CalFresh
benefits worth more than $500, or trading CalFresh
benefits for firearms, ammunition, or explosives
•
lose CalFresh benefits for 12 months for the first offense
and be required to repay all CalFresh benefits overpaid
to me
lose CalFresh benefits for 24 months for the second
offense and be required to repay all CalFresh benefits
overpaid to me
lose CalFresh benefits permanently for the third offense
to me
be fined up to $250,000, imprisoned up to 20 years, or
both
lose CalFresh benefits permanently for the second
offense.
lose CalFresh benefits for 10 years for each offense
•
lose CalFresh benefits permanently
•
•
•
•
Important Information for Noncitizens
•
•
•
You can apply for and get CalFresh benefits for people who are eligible, even if your family includes others who are not
eligible. For example, immigrant parents may apply for CalFresh benefits for their U.S. citizen or qualified immigrant
children, even though the parents may not be eligible.
Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and
confidential.
The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S. Citizenship
and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except
cases of fraud.
Opting Out
You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s)
who are not applying for CalFresh benefits. The County will need to know their income and resource information to correctly
determine your household’s benefits. The County will not contact USCIS about the people who don’t apply for CalFresh
benefits.
Use of Social Security Numbers (SSN)
Everyone applying for CalFresh benefits needs to provide a SSN, if they have one, or proof that they have applied for a SSN
(such as a letter from the Social Security Office). The County may deny CalFresh benefits for you or any member of your
household who does not give us a SSN. Some people do not have to give SSN’s to get help such as, victims of domestic
abuse, crime prosecution witnesses, and trafficking victims.
Overissuance
This means you got more CalFresh benefits than you should have. You will have to pay it back even if the County made an
error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of
benefits owed, through the courts, other collection agencies, or federal government collection action.
Reporting
Every household that gets CalFresh benefits must report certain changes. Your County will tell you what changes to report,
how to report them, and when to report them. Failure to report the changes may result in your CalFresh benefits being
lowered or stopped. You can also report if things happen that may increase your benefits, such as getting less income.
CF 285 (9/13)
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County of Orange
Bid 017-976001-GH
State Hearing
You have the right to a State hearing if you do not agree with any action taken regarding your application or your ongoing
benefits. You can request a State hearing within 90 days of the County’s action and you must tell why you want a hearing.
The approval or denial notice you receive from the County will have information on how to request a State hearing. If you
ask for a hearing before the action happens, you may be able to keep your CalFresh benefits the same until a decision is
made.
Nondiscrimination
It is the State and County’s policy that all people be treated equally, and with respect and dignity. In accordance with federal
law and the U.S. Department of Agriculture (USDA) policy, discriminating on the basis of race, color, national origin, sex,
age, religion, political beliefs, or disabilities is strictly prohibited.
To file a complaint of discrimination, either contact your County’s Civil Rights Coordinator, or write to or call the USDA or
California Department of Social Services (CDSS):
USDA, Director
Office of Civil Rights, Room 326-W
Whitten Building
1400 Independence Ave. S.W.
Washington D.C. 20250-9410
1-202-720-5964 (voice and TDD)
CDSS
Civil Rights Bureau
P.O. BOX 944243, M.S. 8-16-70
Sacramento, CA 94244-2430
1-866-741-6241 (Toll Free)
USDA is an equal opportunity employer.
Privacy Act and Disclosure
You are giving personal information in the application. The County uses the information to see if you are eligible for benefits.
If you do not give the information, the County may deny your application. You have a right to review, change, or correct any
information that you gave to the County. The County will not show your information or give it to others unless you give them
permission or federal and State law allows them to do so. The County will verify this information through computer matching
programs, including the Income and Earnings Verification System (IEVS). This information will be used to monitor compliance
with program regulations and for program management. The County may share this information with other federal and State
agencies for official examination, law enforcement officials for the purpose of arresting persons fleeing to avoid the law, and
private claims collection agencies for claims collection action. The County may verify immigration status of household
members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your
eligibility and level of benefits.
Case File Reviews
Your case may be selected for additional review to ensure that your eligibility was correctly figured. You must cooperate fully
with the County, State, or federal personnel in any investigation or review, including a quality control review. Failure to
cooperate in these reviews could result in loss of your benefits.
Work Rules for CalFresh
The County may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you
have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.
You may not be eligible for CalFresh if you have recently quit a job.
EBT Usage
Any benefit taken from your account before you, another household member, or your authorized representative report the
EBT card or PIN has been lost or stolen will not be replaced.
Any use of your EBT card by you, a household member, your authorized representative, or anyone you voluntarily give your
EBT card and PIN to will be considered approved by you and any benefits taken from your account will not be replaced.
If you do not report that another person you do not want to spend your benefits has your PIN and you do not get your PIN
CF 285 (9/13)
11/19/2013 11:22 AM
p. 27
County of Orange
Bid 017-976001-GH
NOTES
CF 285 (9/13)
11/19/2013 11:22 AM
p. 28
County of Orange
Bid 017-976001-GH
Please use black or blue ink because it is easy to read and copies best. Please print your answers.
If you need more space to answer a question(s), use page 10 “Additional Writing Space” section and attach additional sheets of
paper if needed to provide the information. Please be sure to identify which question you are writing about in the extra space
or on the additional sheets of paper.
1. APPLICANT’S INFORMATION
NAME (FIRST, MIDDLE, LAST)
OTHER NAMES (MAIDEN, NICKNAMES, ETC.)
SOCIAL SECURITY NUMBER (IF YOU HAVE
ONE AND ARE APPLYING FOR BENEFITS)
HOME ADDRESS OR DIRECTIONS TO YOUR HOME
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
STATE
ZIP CODE
HOME PHONE
EMAIL ADDRESS
WORK/ALTERNATE/MESSAGE PHONE
I want to get messages about my case by email.
■
Yes
■
No
Are you homeless? ■ Yes ■ No
If yes, please let the County know right away if you are homeless, so they can help you figure out
an address to use to accept your application and get notices from the county about your case.
What language do you prefer to read (if not English)?__________________________
What language do you prefer to speak (if not English)?_________________________
The County will provide an interpreter at no cost to you. If you are deaf or hard of hearing please check here
■
Do you have a disability and need help with applying?
■
Yes
■
No
Are you interested in applying for Medi-Cal? If you answer yes the County will use your answers to
find out if you can get Medi-Cal.
■
Yes
■
No
Is your household’s monthly gross income less than $150 and cash on hand, or in checking and
savings accounts is $100 or less?
■
Yes
■
No
Is your household’s combined monthly gross income and cash on hand or in checking and savings accounts
is less than the combined cost of rent/mortgage and utilities?
■
Yes
■
No
Is your household a migrant/seasonal farm worker household with liquid resources not exceeding
$100 and either your income stopped or you will not get more than $25 in the next 10 days?
■
Yes
■
No
I understand that by signing this application under penalty of perjury (making false statements), that:
• I read, or had read to me, the information in this application and my answers to the questions in this application.
• My answers to the questions are true and complete to the best of my knowledge.
• Any answers I may give for my application process will be true and complete to the best of my knowledge.
• I read or had read to me and I understand and agree to the Rights and Responsibilities (Program Rules Page 1) for the CalFresh
Program.
• I read, or had read to me, the CalFresh Program Rules and Penalties (Program Rules Pages 2 through 3).
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for
CalFresh is fraud. Fraud can cause a criminal case to be filed against me and/or I may be barred for a period of time (or life) from
getting CalFresh benefits.
• I understand that Social Security Numbers or immigration status for household members applying for benefits may be shared with
the appropriate government agencies as required by federal law.
SIGNATURE OF APPLICANT(OR ADULT HOUSEHOLD MEMBER/ AUTHORIZED REPRESENTATIVE*/GUARDIAN)
DATE
*If you have an Authorized Representative please complete question 2 on the next page.
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 1 OF 10
p. 29
County of Orange
Bid 017-976001-GH
2. HOUSEHOLD’S AUTHORIZED REPRESENTATIVE
You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for you at
the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may get by
mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be replaced. If you
are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.
Do you want to name someone to help you with your CalFresh case?
If yes, complete the following section:
■
Yes
AUTHORIZED REPRESENTATIVE NAME:
■
No
AUTHORIZED REPRESENTATIVE PHONE NUMBER:
Do you want to name someone to receive and spend CalFresh benefits for your household?
NAME:
■
■
Yes
No
PHONE NUMBER:
ADDRESS:
CITY
STATE
ZIP CODE
3. RACE/ETHNICITY
Race and ethnicity information is optional. It is requested to assure that benefits are given without regard to race, color, or national origin.
Your answers will not affect your eligibility or benefit amount. Check all that apply to you. The law says the County must record your ethnic
group and race.
■
Check this box if you do not want to give the County information about your race and ethnicity. If you do not, the County will
enter this information for civil rights statistics only.
If you are of Hispanic or Latino origin, do you consider yourself:
ETHNICITY
■
Are you Hispanic or Latino?
Yes
■
■ Mexican
■ Puerto Rican
■ Cuban
■ Other___________________________________________
No
RACE/ETHNIC ORIGIN
■ White ■ American Indian or Alaskan Native ■ Black or African American ■ Other or Mixed __________________
■ Asian (If checked, please select one or more of the following):
■ Filipino ■ Chinese ■ Japanese ■ Cambodian ■ Korean ■ Vietnamese ■ Asian Indian ■ Laotian
■ Other Asian (specify)________________________________________
■ Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following): ■ Native Hawaiian
■ Guamanian or Chamorro ■ Samoan
4. INTERVIEW PREFERENCE
You will need to have an interview with the County to discuss your application and to receive CalFresh benefits.
Interviews for CalFresh are usually done by phone, unless you can be interviewed when giving your application to the County in person
or would prefer an in-person interview. In-person interviews will only happen during the County’s normal office hours.
■
■
Please check this box if you would prefer an in-person interview.
Please check this box if you need other arrangements due to a disability.
Please check the boxes below for your preferred day and time for an interview:
Day:
■ Today
Time:
■
■
Next available day
Early morning
■
■
Mid-morning
Any day
■
■
Afternoon
Monday
■
■
Tuesday
Late afternoon
■
■
Wednesday
■
Thursday
■
Friday
Anytime
5. OTHER PROGRAMS
Has anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Medicaid, Supplemental Nutrition
Assistance Program [Food Stamps], General Assistance (GA)/General Relief (GR), etc.)?
■
Yes
IF YES, WHO?
WHERE (COUNTY/STATE)?
IF YES, WHO?
CF 285 (9/13)
11/19/2013 11:22 AM
■
No
PAGE 2 OF 10
p. 30
County of Orange
Bid 017-976001-GH
6a. HOUSEHOLD’S INFORMATION
Complete the following information for all persons in the home that you buy and prepare food
with, including you. If applying for noncitizens, please complete question 6b and 6c. If
not, go to question 6d.
APPLYING
FOR
BENEFITS
(✔ check Yes
or No)
NAME
(Last, First, Middle Initial)
How is the
person
related to
you?
Social Security number is optional for
members not applying for benefits. You
must answer the questions below for
each person applying for benefits.
U.S.
CITIZEN or
NATIONAL
(✔ check Yes
DATE
GENDER
or No)
OF BIRTH (M OR F)
If no,
complete
question 6b
below
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
SOCIAL SECURITY
NUMBER
Please list the names of anyone who lives with you that does not buy and prepare food with you:
NAME
NAME
NAME
NAME
6b. NONCITIZEN INFORMATION - Complete for those listed in question 6a above who are not citizens and are applying for aid.
Name
Date of Entry
into U.S.
(if known)
Sponsored?
(✔ check Yes or
No) If yes,
complete
question 6c
below:
Give one of the following (if known):
Passport Number,
Alien Registration Number, etc.
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
DOCUMENT TYPE:_________________________________________________
DOCUMENT NUMBER:______________________________________________
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
Does anyone listed above have at least 10 years (40 quarters) of work history or military service in the USA?
■
Yes ■ No
■
Yes ■ No
■
■
Yes ■ No
■
Yes ■ No
Yes ■ No
If yes, who?____________________________________________________________________________
Does anyone listed above have, or have they applied for, or do they plan to apply for a T-Visa or
U-Visa, VAWA petition?
If yes, who?_______________________________________________________________________________________________
6c. SPONSORED NONCITIZEN INFORMATION - Complete for those listed in question 6b above who are sponsored noncitizens and
are applying for aid.
Did the sponsor sign an I-864? ■ Yes ■ No If yes, please answer the rest of the question. If the sponsor signed an I-134 then
skip this question.
Does the sponsor regularly help with money?
■
Yes ■ No If yes, how much? $____________
Does the sponsor regularly help with any of the following (check all that apply)?
rent
■ clothes ■ food ■ other___________________________________________________________
■
SPONSOR’S NAME
WHO IS SPONSORED?
SPONSOR’S PHONE NUMBER
SPONSOR’S NAME
WHO IS SPONSORED?
CF 285 (9/13)
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PAGE 3 OF 10
p. 31
County of Orange
Bid 017-976001-GH
6d. Students
Is anyone who is applying for benefits attending a college or vocational school?
question.
If no, skip to the next question.
Name of Person
■ Yes ■ No
If yes, please answer this
Enrolled Status
(✔ check one)
Name of School/Training
■
■
Half-time or more
Less than half-time
Number of units:________
■
■
Half-time or more
Less than half-time
Are They Working?
Average work hours
per week:________
Average work hours
per week:________
6e. Is there a foster child living in your home? ■ Yes ■ No If yes, who?_________________________________________
Please answer the following questions about the child(ren):
■ Yes ■ No
Was this child(ren) placed in your home under a dependence order of the court?
■ Yes ■ No
Do you want the foster care child(ren) counted in your CalFresh case? If yes, the foster care
income you receive will be counted as unearned income. If no, the foster care income will not
be counted as unearned income.
7.
Unearned Income
Does anyone you buy and prepare food with get income that does not come from work (unearned)? ■ Yes
If yes, please answer this question. If no, skip to the next question.
Check all types of unearned income that apply from these examples (there may be others not listed here):
■
■
■
■
■
■
■
■
Social Security
SSI/SSP
Cash aid
CalWORKs/TANF/GA/GR/CAPI
Room and board (from your renter)
Pension
Child/Spousal support
■
■
■
■
■
Veteran benefits, or Military pension
Financial aid (school grants/loans/
scholarships)
Gift of money
Unemployment Insurance/
State Disability Insurance (SDI)
Worker’s compensation
Lottery/gambling winnings
Help with rent/food/clothing
Insurance or legal settlements
Private disability or retirement
Strike benefits
Other____________________
_________________________
Government/railroad disability or
retirement
Person getting the money?
■
■
■
■
■
■
■ No
How
much?
From where?
How often received?
(once, weekly, monthly, or
other)
Expect to
continue?
(✔ Check
Yes or No)
$
■ Yes ■ No
$
■ Yes ■ No
$
■ Yes ■ No
$
■ Yes ■ No
If this income is not expected to continue, please explain:
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 4 OF 10
p. 32
County of Orange
8.
Bid 017-976001-GH
Earned income
Does anyone you buy and prepare food with have income from a job (earned income)? ■ Yes ■ No
If yes, please answer this question. If no, skip to the question 9.
NOTE: If self-employed fill out question 8a.
Please list all income before taxes or other deductions are taken out (gross income).
Examples of earned income are (these examples can be full-time, temporary, seasonal, or training, and there may be others not
listed here):
● Work study (students)
Salaries
●
Tips
●
Commissions
●
Wages
●
Employer’s name and Employer’s
address
phone number
Person working
Hourly
rate
How often
Average
paid?
hours per
(Once weekly,
week
monthly, other)
Total gross
earned
income
received
this
month
$
$
$
$
$
$
$
$
Expect to
continue?
(✔ Check
Yes or No)
■ Yes
■ No
■ Yes
■ No
■ Yes
■ No
■ Yes
■ No
Has anyone lost a job, changed jobs, quit a job, or reduced work hours within the last 60 days?
IF YES, WHO?
■ Yes ■ No
DATE OF JOB LOSS, QUIT, OR CHANGE
DATE OF LAST PAY
DATE WENT ON STRIKE
DATE OF LAST PAY
REASON?
Is anyone on strike?
■ Yes ■ No
IF YES, WHO?
REASON?
8a. Self-Employment
Self-employed household members may deduct actual self-employment expenses or take a standard 40% deduction off of
self-employment income. If you choose actual expenses, you will need to give the County proof of the expenses.
Person
self-employed
Date business
started
Gross
monthly
income
Type of business and name
$
$
$
$
$
CF 285 (9/13)
11/19/2013 11:22 AM
Self-employment expenses
(please ✔ check one)
■
■
■
■
■
■
■
■
■
■
40% flat rate
Actual expenses $ ___________
40% flat rate
40% flat rate
40% flat rate
40% flat rate
PAGE 5 OF 10
p. 33
County of Orange
9.
Bid 017-976001-GH
Household’s Child/Adult Care Expenses
Do you or anyone you buy and prepare food with pay for the care of a child, disabled adult,
or other dependent so you or the other person can go to work, school, training, or look for a job?
■ Yes ■ No
Who gives care?
(name and address of provider)
Who gets care?
Amount
paid?
How often
paid?
(weekly/monthly,
other)
$
$
$
$
Does anyone help your household pay all or part of your child/adult care costs listed above?
■ Yes ■ No
Who helps pay?
Who gets care?
If yes, complete below:
Amount
paid?
How often
paid?
(weekly/monthly,
other)
$
$
10. Child Support Payments
Are you or anyone you buy and prepare food with legally obligated to pay child support,
including back child support? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
Who pays child support?
Amount
paid?
Name of child(ren) for whom child support is paid:
How often paid
(weekly/monthly,
other)
$
$
11. Household Expenses
Are you or anyone you buy and prepare food with responsible for any household expenses? ■ Yes ■ No If yes, please answer
this question. If no, skip to the next question.
NOTE: Do not enter amounts paid by housing assistance such as HUD or Section 8. The heating and cooling, telephone, other
utilities, and the homeless shelter are set allowances and you do not need to fill in the actual amount owed.
How often billed?
Amount
Have
Type of Expenses
Who pays?
(weekly/monthly)
Owed
Expense?
$
Rent or house payment
■ Yes ■ No
Property taxes and insurance (if billed separately from
$
rent or mortgage)
■ Yes ■ No
Gas, electric, or other fuel used for heating or cooling,
such as firewood or propane (if billed separately from ■ Yes ■ No
rent or mortgage)
Telephone/cell phone
Homeless Shelter Expense
Water, sewage, garbage
Does anyone not in your household help you pay for the
expenses listed above? ■ Yes ■ No If yes, please
complete.
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
Who helps pay?
How much?
$
How often paid?
Does your household receive, or expect to receive, payment from the Low Income Home Energy Assistance
Program (LIHEAP)?
■ Yes ■ No
CD 285 (9/13)
11/19/2013 11:22 AM
PAGE 6 OF 10
p. 34
County of Orange
Bid 017-976001-GH
12. Medical Expenses:
Are you or anyone you buy and prepare food with an elderly (60 or older) or disabled person that has any out-of-pocket medical
expenses? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
NOTE: Do not list spouses or children receiving dependent payments for an SSI or disability and blindness recipient.
List expenses you expect to have in the near future.
Allowable medical expenses are:
■
■
■
■
■
Medical or dental care
Hospitalization/outpatient
treatment/nursing care
■
■
Prescribed medications
Health and Hospitalization
insurance policy premiums
■
■
Medicare premiums (Medi-Cal share of
costs, etc.)
Dentures, hearing aids and prosthetics
Maintaining an attendant necessary due
to age, illness, or infirmity
The number and cost of meals
furnished to an attendant
Prescribed over the counter medications
Amount of
expense
Name of elderly/disabled person
■
■
■
■
Cost of transportation (mileage or fee)
and lodging to obtain medical treatment
or services
Prescribed eye glasses and contact
lenses
Prescribed medical supplies and
equipment
Service animals expenses
(food, vet bills, etc.)
What type of
Will the household be reimbursed
How often
expense?
for any medical expenses?
paid?
(prescriptions,
(by Medi-Cal, insurance,
dentures,
(monthly, weekly,
number of meals for
family member, etc.)
other)
attendant, etc.)
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
13. Does anyone get food from any of the following?
question.
● Communal dining facility for the elderly/disabled
■ Yes ■ No
●
Food distribution program operated
by a Native American reservation
IF YES, WHO?
WHERE?
IF YES, WHO?
WHERE?
14. Does anyone live at any of the following?
●
●
●
●
●
■ Yes ■ No
Homeless Shelter
Shelter for battered women
Reservation for Native Americans
Drug/Alcohol rehabilitation center
Correctional facility/Penal institution (Jail or Prison)
Person’s Name
If yes, please answer this question. If no, skip to the next
●
Other food program
●
●
●
●
●
Group living arrangement for the blind/disabled
Federally subsidized housing
Psychiatric hospital/mental institution
Hospital
Long-Term Care or Board and Care Facility
Name of Institution (center, shelter, facility, etc.)
Expected Date of Release
(if applicable)
15. Is anyone living with you age 60 or older and unable to buy food and fix meals separately
because of a disability?
■ Yes ■ No
IF YES, WHO?
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 7 OF 10
p. 35
County of Orange
Bid 017-976001-GH
16.
Household’s Resources
Do you or anyone you buy and prepare food with have any resources (cash, money in the bank, Certificate of Deposit,
stocks and bonds, etc.)? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
Check each resource listed below:
■
■
■
■
Bank/Credit Union account (Checking)
Bank/Credit Union account (Saving)
Safe Deposit box
Savings Bond(s)
■
■
■
■
Money Market Account
Mutual Funds
Certificate of Deposit (CD)
Cash on hand
■
■
■
Stocks
Bonds
Other: ____________________
If joint account with another person please say so below.
For each box checked above, complete the following information.
In whose name is the
resource listed?
What type of resource?
How much is
it worth?
Where is the resource?
(include the name of the bank or company
where money is held)
$
$
$
$
Have you or anyone in your household sold, traded, given away, or transferred a resource in the last three months?
17.
18.
19.
20.
21.
22.
Duplicate Benefits
Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP
(federal name for food assistance program, known as CalFresh in California) benefits in any state
after September 22, 1996?
If yes, who?_______________________________________________________________
Trafficking Benefits
Have you or any member of your household ever been convicted of trafficking (allowing use of or
selling EBT cards to others) SNAP benefits of $500 or more after September 22, 1996?
If yes, who?_______________________________________________________________
Trading Benefits for Drugs
Have you or any member of your household been found guilty of trading SNAP benefits for drugs
If yes, who?_______________________________________________________________
Trading Benefits for Firearms or Explosives
Have you or any member of your household been found guilty of trading SNAP benefits for guns,
ammunition, or explosives after September 22, 1996?
If yes, who?_______________________________________________________________
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
Fleeing Felon
Are you or any member of your household hiding or running from the law to avoid prosecution, being
taken into custody, or going to jail for a felony crime or attempted felony crime?
If yes, who?_______________________________________________________________
■ Yes ■ No
Probation/Parole Violation
Have you or any member of your household been found by a court of law to be in violation of
probation or parole?
If yes, who?_______________________________________________________________
■ Yes ■ No
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 8 OF 10
p. 36
County of Orange
23.
Bid 017-976001-GH
Drug Felony
Have you or any member of your household, been convicted of felony possession, use, or distribution of
a controlled substance (illegal drugs or certain drugs for which a doctor’s prescription is required) after
August 22, 1996?
If yes, and the felony conviction was for possession, have you or that household member done
(or will do) any of the following:
■ Yes ■ No
a) Completed a government-recognized drug treatment program?
■ Yes ■ No
b) Participated in a government-recognized drug treatment program?
■ Yes ■ No
c) Enrolled in a government-recognized drug treatment program?
■ Yes ■ No
d) Been placed on a waiting list for a government-recognized drug treatment program?
■ Yes ■ No
e) Stopped the use of controlled substances and have evidence that you have stopped?
■ Yes ■ No
If yes, please explain:_______________________________________________________________
________________________________________________________________________________
Additional Writing Space
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 9 OF 10
p. 37
County of Orange
Bid 017-976001-GH
DO NOT COMPLETE - COUNTY USE ONLY
IF THE ANSWER IS YES TO ANY OF THE QUESTIONS BELOW - EXPEDITE
Is the household’s gross income less than $150 and cash on hand, or in checking and
savings accounts $100 or less?
■ Yes ■ No
Is the household’s combined gross income and cash on hand or on checking and savings accounts
less than the combined rent/mortgage and appropriate utility allowance?
■ Yes ■ No
Is the household a destitute migrant/seasonal farm worker household with liquid resources
not exceeding $100 and does not expect to receive more than $25 in next 10 days?
■ Yes ■ No
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 10 OF 10
p. 38
County of Orange
Bid 017-976001-GH
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
(Check One)
Already registered. I am registered to vote at my current residence address.
Yes.
I would like to register to vote. (Please fill out the attached voter registration form.)
No.
I do not want to register to vote.
NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO
VOTE AT THIS TIME. YOU MAY TAKE THE ATTACHED VOTER REGISTRATION FORM TO REGISTER AT
YOUR CONVENIENCE.
___________________________________________________________________
Applicant Name
Date
Important Notices
1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this
agency.
2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the voter registration form in private.
3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in
deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or
other political preference, you may file a complaint with the Secretary of State by calling toll-free
(800) 345-VOTE (8683)
or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. For more information on elections and
voting, please visit the Secretary of State’s website at www.sos.ca.gov.
01/13 NVRA Voter Preference Form
11/19/2013 11:22 AM
p. 39
County of Orange
Bid 017-976001-GH
DO YOU KNOW?
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County of Orange
Bid 017-976001-GH
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11/19/2013 11:22 AM
p. 41
County of Orange
Bid 017-976001-GH
CALFRESH BENEFITS
HOW TO REPORT HOUSEHOLD CHANGES
Everyone who receives CalFresh benefits must report when their income or household situation changes. If you’re not
sure how to report changes, what changes to report, or what proof we need, be sure to ask your worker. You are
receiving this notice because:
■ You have been approved for CalFresh benefits and will be reporting changes on a Change Reporting basis.
■ Your household was previously assigned Semi-Annual Reporting status and will now be reporting on a Change
Reporting basis.
Change Reporting requirements are described below.
CHANGE REPORTING
You MUST report the following changes within ten days:
•
•
•
•
•
•
•
•
If your household has a change in the source of monthly
earned income, or your household’s monthly earned
income starts, stops, or changes by more than $100.00.
unearned income, or your household’s monthly unearned
Anyone’s source of income changes.
You move in with someone else or anyone moves into or
out of your home, including newborns, other children,
spouses, other relatives or non-relatives.
Anyone moves to another address, plans to move or gets a
new mailing address.
Your household’s total cash, stocks, bonds or other money
is more than $2000 (or $3250 if someone in your household
is age 60 or over or disabled).
If there is a change in the amount of any court ordered child
support paid by a member of the household for a child not
living in the home.
If you are meeting the Able Bodied Adult Without
Dependents (ABAWD) work rule by working and your work
hours drop below 20 hours a week or 80 hours a month.
CalFresh rules limit the receipt of CalFresh benefits to 3
months in a 3-year period for ABAWDs who are not working
or participating in other allowable activities. You are
excused from the ABAWD work rule and do not need to
report a drop in your work hours if you are:
• Living in a county where the ABAWD work rule is
waived because of high unemployment rates;
• Under 18 or 50 years of age or older;
• Medically certified as physically or mentally unfit for
employment’
• Meeting the CalWORKs Welfare-To-Work rules
• Caring for an injured or sick person who will need help
for more than 30 days;
• Participating in an alcohol or drug treatment program
that keeps you from working 30 hours or more per
week;
• Getting or have applied for Unemployment Insurance
benefits;
• Employed or self-employed at least 30 hours per week
or receiving weekly earnings at least equal to the
federal minimum wage multiplied by 30 hours;
• Going to school at least half-time;
• Pregnant; or
• Living in a CalFresh household that contains a minor
child even if the minor child is not eligible for CalFresh
benefits.
•
•
If, since your last report, anyone in your home has been
avoiding or running from the law to avoid a felony
prosecution, custody or confinement after conviction, or is
in violation of probation or parole.
convicted after August 22, 1996 of a drug-related felony for
manufacturing, sale, or distribution of a controlled
substance, or any activity in connection with these unlawful
acts, or harvesting, cultivating or processing marijuana, or
involving a minor in the above activities.
You MAY report when:
•
•
•
•
•
Anyone’s physical or mental illness begins or ends.
Anyone’s citizenship, immigration status changes or anyone
gets a letter, form or new card from the U.S. Citizenship and
Immigration Services (USCIS) (formerly INS).
You have changes in your dependent care costs.
Any member who is disabled or age 60 or older has
changes in or new medical expenses. If verified, your
allotment can be refigured.
Any member begins to pay court-ordered child support for a
child not living in the home.
You may report changes either:
•
•
By mail, telephone, or in person at the County CalFresh
Office; or
By turning in a CF 377.5 CR CalFresh Household Change
Report form.
TRANSITIONAL CALFRESH BENEFITS
California’s Transitional CalFresh program provides CalFresh
benefits for five months to households that leave CalWORKs. If
your household begins receiving transitional CalFresh benefits,
you do not have to report while receiving these benefits.
If you are receiving transitional CalFresh benefits, you may
reapply to see if you can get more benefits. If you reapply and
are approved for regular CalFresh benefits, then all normal
reporting rules will apply.
CF 23 CR (9/13) REQUIRED FORM - SUBSTITUTE PERMITTED
11/19/2013 11:22 AM
p. 42
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 43
County of Orange
Bid 017-976001-GH
CALFRESH BENEFITS
sure how to report changes, what changes to report, or what proof we need, be sure to ask your local county office. You
are receiving this notice because:
■ You have been approved for CalFresh benefits and will be reporting changes on a Semi-Annual basis.
■ Your household was previously assigned Change Reporting status and will now be reporting on a Semi-Annual basis.
Semi-Annual Reporting requirements are described below.
SEMI-ANNUAL REPORTING
As a semi-annual reporting household, you will need to turn in a
completed Semi-Annual Report form (SAR 7) due by the 5th
day of the 6th month after your most recent certification. If you
do not turn in your completed SAR 7 by the end of the first
working day of the next (7th) month, your benefits will stop.
Your worker will use the income and expense information
reported on the SAR 7 to calculate your CalFresh benefits for
the remainder of the certification period.
For example:
You completed your annual recertification in May. Your SAR 7
will be due 6 months later, on November 5th and you will report
what income you had in October. You will also report any
income changes you expect to have in December, January,
February, March, April and May. You must turn in your
completed SAR 7 by no later than the first working day in
December or your benefits will stop. You will lose benefits
unless you had a good reason for being late. Your annual
recertification will be due in May six months later. Your next
SAR 7 will be due for the following certification period six
months later.
What you must report on a
Semi-Annual Report (SAR 7):
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Earned income from any source;
Unearned income of any kind;
Anyone getting free rent or utilities;
Anyone who has expenses that are paid by someone else;
Reduced hours of work or training;
Someone moves in/out of your home;
If you move;
Any real or personal property bought, sold or exchanged;
Any change in legally obligated child support paid by a
household member;
Anyone’s citizenship/immigration status changes or
receives correspondence from the U.S. Citizenship and
Immigration Services (USCIS) (formerly INS);
Anyone reaches 60 years of age;
Anyone gets a job or payments for training or school
expenses;
Anyone has a job, training or school costs such as for
dependent care or supplies;
manufacturing, sale , or distribution of a controlled
REPORTING MANDATORY CHANGES DURING THE
CERTIFICATION PERIOD
You must report the following changes within ten (10) days even
if it is not your report month. You are to report:
•
•
When your household’s income is more than 130% of
federal poverty level, for your household size (CalFresh
IRT).
•
Living in a county where the ABAWD work rule is
•
Under 18 or 50 years of age or older;
•
Medically certified as physically or mentally unfit for
employment;
•
Meeting the CalWORKs Welfare-To-Work rules;
•
Caring for an injured or sick person who will need help
•
Participating in an alcohol or drug treatment program
week;
•
Getting or have applied for Unemployment Insurance
benefits.
REPORTING VOLUNTARY CHANGES
You may also report other information voluntarily, even when it is
not your report month. Reporting information voluntarily may
cause your household benefits to go up or down. See examples
below. The county will take action within ten (10) days after you
provide verification. One exception is when the increase results
from adding another person to your case. In that situation, the
county will take action to increase benefits the first of the month
after you provide verification. Even if you have already
reported something to the County, you must also report it
on your next SAR 7 or recertification.
Some examples of voluntary reporting that may cause your
benefits to go up include:
•
Loss of income;
•
Member becomes disabled or 60 years old;
•
Member begins to pay court-ordered child support;
•
New household member in the home;
•
Shelter/housing cost increases;
•
Medical expenses.
(Continued on back)
CF 23 SAR (6/13) REQUIRED FORM - SUBSTITUTE PERMITTED
11/19/2013 11:22 AM
p. 44
County of Orange
Bid 017-976001-GH
REPORTING VOLUNTARY CHANGES - Continued
benefits to go down include:
•
Gain or increase of income that is less than your CalFresh
IRT;
•
Someone with no income moves out of your home;
•
Someone in your home who had no income dies;
•
Someone with income moves into your home;
•
Shelter cost decrease.
benefits for five months to households that leave CalWORKs.
You MAY report changes during your households certification
period either by:
•
If your household begins receiving transitional CalFresh
benefits, you do not have to report while receiving these
benefits.
If you are receiving Transitional CalFresh benefits, you may
Mail, telephone or in person at the county CalFresh office
or by turning in a Mid-Certification Period Status Report or
SAR 3.
OTHER CHANGES
There are other circumstances that will require the county to
decrease or discontinue your benefits during the certification
period in which they happen. Here are some examples:
•
A household member is sanctioned;
•
Someone in your household receives benefits in another
household;
•
A California Food Assistance Program status changes.
11/19/2013 11:22 AM
p. 45
County of Orange
Bid 017-976001-GH
IMPORTANT INFORMATION - PLEASE READ
New Reporting Requirements for Cash Aid and CalFresh
The county is changing from Quarterly Reporting
to Semi-Annual Reporting. Below are the changes
that will be coming soon. We will tell you when
these new rules start.
Reporting Form
Before, you turned in a QR 7 every 3 months.
Soon you will only need to turn in a report
once every 6 months.
The 6-month report form is called the SAR 7.
The other report will be your annual redetermination/recertification (RD/RC) form.
The SAR 7 is due 6 months after your annual
RD/RC. It is always due on the 5th day of the
month. If you do not turn in your complete SAR 7
by the end of the first working day of the next (7th)
month, your aid will stop.
Example: You completed your annual RD/RC in
February. Your SAR 7 will be due 6 months later,
on August 5th. You have to get your completed
SAR 7 to your worker no later than the first
working day in September or your benefits will
stop. You will lose aid unless you had a good
reason for being late.
For Cash Aid: The amount of income that you
have to report within 10 days is changing. The
IRT is based on your total income and the number
of people in your household. Before, we would
stop your benefits if your total income was over
the IRT. Under the new rules, when you report
income over your IRT, the county may lower or
stop your benefits.
Example: If your IRT is $900 and you get income
of $800 you do not have to report the change until
your next report is due. If you get income of $901
or more you must report it to your worker within
10 days. Your benefits will go down and your
worker will give you a new IRT.
For CalFresh: Before, you did not have an IRT.
Soon you will have an IRT based on your
household size. When you report income over
your IRT, the county may stop your benefits.
Other Mandatory and Voluntary Reporting
Rules are the same.
Voluntary reports may increase your benefits.
Just like with your QR 7, you must answer all the
questions on the SAR 7, attach proof, sign and
date it, and return it by the date listed on the
report.
Changes to the Income Reporting Threshold
(IRT) Rules
The IRT is the amount of total monthly income that
you have to report within 10 days. By “total
monthly income” we mean any money you get.
Any time your IRT changes, the county will let you
know in writing.
TEMP SAR 1 (10/12) NEW REPORTING REQUIREMENTS FOR CASH AID AND CALFRESH
11/19/2013 11:22 AM
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County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 47
Build a Better Future
for your Family
11/19/2013 11:22 AM
Get the benefits of family planning
services, which can help you:
• Improve your ability to become selfsufficient by preventing an unplanned
pregnancy.
• Plan the number and spacing of your
children so you are able to meet the
economic and emotional needs of
your family.
• Communicate with your partner about
reproductive health issues.
• Talk to your kids about safe sex and
pregnancy prevention.
County Stamp Box
California Family Planning Information
and Referral Service
1-800-942-1054
State of California
Health and Human Services Agency
Department of Social Services
PUB 275 (04/07)
Family Planning...
Making the Commitment
for a Healthy Future
County of Orange
Do it for yourself.
Do it for the ones you love.
p. 48
Bid 017-976001-GH
• Answer questions about all your
reproductive health concerns.
• Learn how to do self-exams to check
for breast cancer.
• Get screened for reproductive
cancers.
• Learn how to prevent getting and
spreading sexually transmitted
diseases, including HIV/AIDS.
• Get tested and treated for sexually
transmitted diseases.
• Learn about emergency contraception
and whether it will be the right choice
for you if you ever need it.
• Get birth control supplies to help
prevent an unplanned pregnancy.
1-800-942-1054
• Call the California Family Planning
Information and Referral Service for
the name, address and phone number
of a family planning services provider
in your area at:
Make the commitment today.
• Inexpensive — CalWORKs clients
can receive them for no- and
low-cost.
• Available for men and women,
including teens.
• Confidential, which means it is
private between you and your
doctor.
These services are:
• From your doctor, county department
of health or your health care plan.
• Find the birth control method that fits
your lifestyle. There is a wide range of
choices — from the pill to the ring to
the shot and more.
• Look in the telephone yellow pages
under “Family Planning Information.”
Get family planning services in
your community:
11/19/2013 11:22 AM
Your local family planning provider
can help you:
Family Planning — For Your Family’s Future
County of Orange
Bid 017-976001-GH
p. 49
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You cannot get your wheelchair into
examination, interview rooms or restrooms.
Men get referred to job training for better
paying jobs than women.
The county does not want you to have training
because they say you are “too old.”
You are not allowed to adopt a baby because you
are of a different race.
DISCRIMINATION COMPLAINTS
If you think you have been discriminated against, you may
submit a complaint application separately to the County
or the State, and the Federal Government. The Federal
agency that you must complain to depends on which
program your complaint is about.
You can file a discrimination complaint with:
1. FOR ALL PROGRAMS ADMINISTERED BY
YOUR COUNTY WELFARE DEPARTMENT:
The County’s Civil Rights Coordinator. Ask
your county office for the name, address and
phone number of their Civil Rights
Coordinator. He/she will independently
investigate your complaint.
2. Civil Rights Bureau
California Department of Social Services
744 P Street, MS 8-16-70
Sacramento, CA 95814
(916) 654-2107
(866) 741-6241 (Toll-Free)
3. FOR THE CALFRESH PROGRAM:
United States Department of Agriculture
Director, Office of Civil Rights,
Room 326-W, Whitten Bldg.
1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410
(202) 720-6382 (voice and TTY)
4. FOR ALL OTHER PROGRAMS:
Health and Human Services
Office of Civil Rights
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310 (voice)
(415) 437-8311 (TDD)
TIME LIMITS TO TAKE ACTION
If you suffer discrimination, you must submit your
complaint within 180 days of the actual
discrimination. If the discrimination also affected
the level of your benefits and services, you must also
ask for a state hearing within 90 days. A
discrimination investigation cannot change your
benefit levels or services…only a state hearing can
do that.
LIMITS ON CERTAIN RIGHTS
Although you have the right to privacy and
confidentiality, there are certain laws that allow
limited exceptions. You can ask the county for
the laws.
QUESTIONS
If you have any questions about the rights listed
here, call the Public Inquiry Unit: toll free
(800) 952-5253. The TDD toll-free telephone
number is (800) 952-8349.
■
Adoption Assistance Program (AAP)
Adult Protective Services
Alcohol and Drug Program
California Food Assistance Program (CFAP)
Medi-Cal
CalWORKs
CalWORKs Child Care
CalWORKs Welfare-to-Work Program/Services
Cash Assistance Program for Immigrants (CAPI)
Child Welfare Services
Denti-Cal
Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT)
CalFresh (Food Stamps)
Foster Care
In-Home Support Services
Kinship Guardian Assistance (Kin-GAP)
Mental Health
PROGRAMS COVERED BY THIS PAMPHLET
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Multipurpose Senior Services Program (MSSP)
Personal Care Services Program (PCSP)
Refugee Cash Assistance
Social Services
STATE OF CALIFORNIA
HEALTH AND HUMAN
SERVICES AGENCY
DEPARTMENT OF
SOCIAL SERVICES
This pamphlet is available from your Local
County Welfare Office and at www.cdss.ca.gov in
the following languages:
• Arabic
• Japanese • Russian
• Armenian • Korean • Spanish
• Cambodian • Lao
• Spanish Large Print
• Chinese
• Tagalog
• Mien
• Farsi
• Portugese • Ukranian
• Hmong
• Punjabi • Vietnamese
Also Available in large print, Braille, and Audio CD
PUB 13 (6/11)
YOUR
RIGHTS
UNDER CALIFORNIA
WELFARE PROGRAMS
… for people applying for
or receiving public aid in
California
Tell us if you need help
because of a disability
Ask for a free interpreter
County of Orange
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11/19/2013 11:22 AM
p. 50
Bid 017-976001-GH
11/19/2013 11:22 AM
1. Understand what is happening with your
application and aid.
YOU HAVE A RIGHT TO…
All people and organizations providing public
assistance must respect your rights. They can help
you understand and apply for benefits and services.
YOUR RIGHTS
1. Keep records of all your information,
documents, and contacts with the county.
2. Get a receipt when you turn anything in.
3. You can bring someone with you to a meeting
with your worker.
4. Complain. There are 4 ways to do this:
■ Informal: You can ask to speak to a supervisor to
talk about problems with a worker or to go
over the rules and the proposed action on your
aid or services.
■ State Hearing: Ask for a state hearing if there is a
problem with your aid or services. You must
ask for a hearing within 90 days of the county's
action. You may be able to file after 90 days if
you have a good reason, like illness or a
disability.
■ Discrimination complaint: If you feel that the
county has discriminated against you, you can
make a discrimination complaint to the
County’s Civil Rights Coordinator or to the
State Civil Rights Bureau, and to the Federal
Government. You must do this within 180 days
of the discrimination. For more on this, see the
section beginning “Prohibited Discrimination.”
IF YOU ARE HAVING PROBLEMS WITH YOUR AID
OR SERVICES:
2. Get written and oral explanations about your
application and aid.
3. Get a receipt for any documents you turn in.
4. See your case record.
5. See state and county laws and regulations.
6. Ask a judge to review any county decision about
your eligibility, benefits, or services.
7. Not face discrimination in receiving program
benefits or services.
8. File a complaint about discrimination.
9. Get extra help from county staff to make sure
you get your benefits if you have a disability or
impairment that makes it hard to understand
the program rules.
10. Have your information kept confidential.
11. Be treated with courtesy and respect.
You can ask for a state hearing any time you
disagree with a county’s action on your benefits
or services.
You can also ask for a state hearing if the county
is not giving you benefits or services which you
think you should get.
A state hearing is heard by a state Administrative
Law Judge. The county will have someone at
the hearing to explain why they took their
action.
A state hearing is not a court hearing. You do
have the right to have a representative with you.
There are free legal services in every county. They
are listed on the back of your county notices.
You can bring witnesses. You have the right to a
free interpreter. Ask the county how to get one.
• If your problem is with General Assistance
or general relief, you must ask for a county
hearing.
• If your problem is with Social Security
benefits, you must contact the Social
Security Administration.
The county must give you a notice at least 10 days
before any action to change your aid or services takes
place. If you ask for a hearing before the action takes
place, you can get “aid paid pending” your hearing.
This means your aid stays the same until you get a
hearing decision.
You MUST ask for a hearing on any new
notice you get, if you disagree.
CONTINUING YOUR AID OR SERVICES PENDING
A STATE HEARING
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STATE HEARINGS
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If the discrimination also affects your benefits or
services, you must also ask for a state hearing if
you wish to challenge the county’s decision on
your benefits or services.
Grievance: You can file a complaint with the
county if they have a grievance procedure. This
does not protect your beneﬁts in the way that
asking for a state hearing does.
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Bid 017-976001-GH
The County does not give you a free interpreter.
A worker tells a certain ethnic group about more
programs and services than people of other
ethnicities.
The County won’t help you get audio tapes of a
program orientation to help you with a
disability that makes it hard for you to read.
A worker learns of your religion or politics and
then treats you differently.
You can’t get to appointments because the
county building does not have an elevator.
EXAMPLES OF DISCRIMINATION
Under State law, welfare agencies may not provide
you aid, benefits or services that is different from aid
provided to others on the basis of
Race, Color, National Origin (including
language), Ethnic Group Identification, Age,
Disability, Religion, Sex, Sexual Orientation,
Political Affiliation, Marital Status, or
Domestic Partnership
Federal laws also prohibit discrimination on several,
although not all, of the bases listed above.
Federal Law also prohibits :
1. Delaying or denying the placement of a child for
adoption or into foster care on the basis of race,
color or national origin of the adoptive or foster
parents, or the child;
2. Denying to any individual the opportunity to
become a foster or adoptive parent on the basis
of race, color or national origin of the individual
or child involved.
PROHIBITED DISCRIMINATION
1. Phone: Ask for a State Hearing by contacting
the CA Department of Social Services at
(800) 743-8525 or (800) 952-5253
2. Fill out the back of your Notice of Action
(NOA) or send a written request to:
CDSS, State Hearing Division
744 P Street M.S. 09-17-37
HOW TO REQUEST A STATE HEARING
County of Orange
p. 51
County of Orange
Bid 017-976001-GH
Req # 1055787
1
English
NACF PHONE-IN RRR
December 2013
Region
Quantity
ARC
5,000
AVRC
1,600
CRO
2,500
GGRC
3,500
SARC
3,325
TOTAL
15,925
2 STAPLES LEFT SIDE
11/19/2013 11:22 AM
p. 52
County of Orange
Bid 017-976001-GH
Req # 1055788
2
Spanish
NACF PHONE-IN RRR
December 2013
Region
Quantity
ARC
3,250
AVRC
450
CRO
100
GGRC
1,225
SARC
3,900
TOTAL
8,925
2 STAPLES LEFT SIDE
11/19/2013 11:22 AM
p. 53
County of Orange
Bid 017-976001-GH
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11/19/2013 11:22 AM
p. 54
County of Orange
Bid 017-976001-GH
AVISO SOBRE LA RECERTICACION DE ESTAMPILLAS DE COMIDA
Usted fue notificado que su periodo de certificación de Estampillas de Comida
terminara el próximo mes y que recibirá una cita para que sus beneficios continúen.
Usted ha sido citado para una entrevista por teléfono. Un trabajador le llamara al
número de teléfono que usted proveyó previamente.
Por favor llame al trabajador lo antes posible si:
x
El día y la hora de la entrevista no es conveniente para usted y desea cambiar la
cita.
x
Usted desea que el trabajador le contacte a otro numero de teléfono (como su
celular o al trabajo).
x
Usted prefiere ser entrevistado en persona y desea solicitar una cita en la oficina.
Por favor, firme, y feche los documentos requeridos adjuntos (Aplicación para
beneficios de Estampillas de Comida/DFA 285-A1, Declaración de Hechos/DFA
285-A2, y Sus Derechos y Responsabilidades/DFA 285-A3 QR. Devuélvanos
inmediatamente estos documentos en el sobre prepagado. Los otros materiales
provistos son para su información/registros. Necesitamos tener los documentos
completos para revisarlos antes de la entrevista por teléfono. Si necesitamos
algún otro documento se lo comunicaremos después de que los revisemos o
durante la entrevista por teléfono.
RECORDATORIO IMPORTANTE
x
Si no completa la entrevista, esto causara que sus beneficios de Estampillas de
Comida terminen.
x
Si no mantiene su cita para la entrevista, es su responsabilidad de establecer
otra cita.
x
No es obligatorio completar su Reporte Trimestral QR7 en el mismo mes que su
re-certification es completada. Sin embargo, verificaciones de ingresos de todos
los miembros del hogar son requeridos. Por favor inclúyalos cuando retorne
estas formas.
x
Las verificaciones que necesitamos deben de ser provistas dentro de 10 días
después de requerirlas.
11/19/2013 11:22 AM
p. 55
County of Orange
Bid 017-976001-GH
MEJORES ALIMENTOS PARA UNA VIDA MEJOR
SOLICITUD PARA BENEFICIOS DE CALFRESH
Si usted tiene una incapacidad/discapacidad o necesita ayuda con esta solicitud, comuníqueselo al Departamento
de Bienestar Público del Condado (Condado) y alguien le ayudará.
Si prefiere hablar, leer, o escribir en un idioma que no es inglés, el Condado conseguirá a alguien para que le
ayude sin costo para usted.
¿Cómo presento una solicitud?
Use esta solicitud si solamente está solicitando beneficios de CalFresh. CalFresh es un programa de asistencia
alimentaria para ayudarle con el costo de comprar alimentos para su hogar. Si quiere solicitar beneficios de
otros programas que no son CalFresh, tales como CalWORKs (Programa de California de Oportunidades de
Trabajo y Responsabilidad hacia los Niños) o Medi-Cal (Programa de Asistencia Médica de California), pida una
solicitud para esos programas. Usted también puede solicitar en línea los beneficios de CalFresh y de otros
programas en: http://www.benefitscal.org/. También puede ver en línea si es posible que sea elegible en:
http://www.cdss.ca.gov/foodstamps/PG849.htm.
• Si puede, complete todo el formulario de solicitud. Para empezar el proceso de solicitud, usted tiene que al
menos proporcionarle al Condado su nombre, dirección y firma (Pregunta 1 en la Página 1).
• Entregue la solicitud al Condado, ya sea en persona, por correo, por fax, o en línea.
• El día que el Condado recibe su solicitud firmada, es la fecha cuando empieza a contar el tiempo para darle
una respuesta sobre si usted puede recibir beneficios. Si usted está en una institución, el tiempo comienza el
día que usted se va de la institución.
¿Qué es lo que debo hacer?
• Antes de firmar la solicitud, lea acerca de sus derechos y responsabilidades (Páginas 1 al 3 de las páginas
marcadas en inglés “PROGRAM RULES” [“Reglas del Programa”]).
• Usted tiene que tener una entrevista con el Condado para hablar acerca de su solicitud. La mayoría de las
entrevistas se llevan a cabo por teléfono pero se pueden hacer en persona en la oficina del Condado u otro
lugar acordado con el Condado. Si usted tiene una incapacidad/discapacidad, se pueden hacer otros arreglos.
• Si usted no completó toda la solicitud, puede completarla durante su entrevista.
• Para ver si usted es elegible, necesitará proporcionar pruebas de sus ingresos, gastos, y otras circunstancias.
¿Cuánto tiempo se tomará?
Es posible que el proceso de su solicitud se tarde hasta 30 días. Usted puede recibir beneficios antes de que
pasen 3 días consecutivos si:
• Los ingresos brutos (ingresos antes de las deducciones) mensuales de su hogar son menos de $150 y el
dinero que tiene en efectivo o en una cuenta de cheques o de ahorros es $100 o menos; o
• El costo de vivienda de su hogar (renta/pago de hipoteca y servicios públicos y municipales) son más que sus
ingresos brutos mensuales y el dinero en efectivo o en cuentas de cheques o ahorros; o
• Usted es un migrante o un trabajador campesino de temporada y su hogar tiene menos de $100 en cuentas
de cheques o de ahorros y 1) sus ingresos se descontinuaron, o 2) sus ingresos empezaron pero no espera
recibir más de $25 en los siguientes 10 días.
Para ayudarle al Condado a determinar si usted puede recibir beneficios en tres días, por favor conteste las
Preguntas 1, 6 al 8, 11, y 16, y proporcione al Condado pruebas de su identidad (si las tiene) junto con su solicitud.
El Condado le enviará una carta para avisarle si su hogar está aprobado o no para recibir beneficios de CalFresh.
Página de información - Por favor consérvela para sus expedientes.
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
p. 56
County of Orange
Bid 017-976001-GH
¿Qué necesito para mi entrevista?
Para evitar demoras, tenga lo siguiente para su entrevista. Asista a la entrevista aunque no tenga las pruebas.
Es posible que el Condado le pueda ayudar para obtener las pruebas. Durante la entrevista, el Condado
repasará la información en la solicitud y le hará preguntas para ver si puede recibir beneficios de CalFresh y
cuál cantidad de beneficios puede recibir.
Pruebas que necesita para recibir más
Pruebas que necesita para recibir beneficios
• Identificación (Licencia de manejar, tarjeta de identificación
beneficios de CalFresh
del Estado, pasaporte).
• Costos de vivienda (recibos de renta, cobros
• Pruebas del lugar donde vive (un contrato de
de hipoteca, cobros de impuestos sobre la
arrendamiento, cobro actual con su dirección).
propiedad, documentos de seguro).
• Números de Seguro Social (vea la nota que aparece abajo
• Costos de servicios de teléfono y servicios
acerca de ciertas personas que no son ciudadanas).
públicos y municipales.
• Dinero en el banco para todas las personas en su hogar
• Gastos médicos para todas las personas en su
(estados de cuenta de banco recientes).
hogar que son de edad avanzada (60 años o
• Ingresos ganados por todas las personas en su hogar para
más) o que están incapacitadas/discapacitadas.
los últimos 30 días (talones de cheques de pago recientes,
• Costos para el cuidado de niños o adultos
una declaración de un empleador).
debido a que alguien está trabajando,
NOTA: Si trabaja por cuenta propia, ingresos y gastos o
buscando trabajo, asistiendo a un
registros de impuestos.
entrenamiento o escuela, o está participando
• Ingresos no ganados (beneficios de desempleo, Ingresos
en una actividad de trabajo requerida.
Suplementales de Seguridad [SSI], Seguro Social,
• Mantenimiento de hijos pagado por una
beneficios para veteranos, mantenimiento de hijos,
persona en su hogar.
compensación por lesiones de trabajo, subvenciones o
préstamos escolares, ingresos provenientes de
arrendamientos, etc.).
• Situación migratoria legal SOLAMENTE para personas que
no son ciudadanas que están solicitando beneficios (tarjeta
de residente legal, visa).
NOTA: Es posible que ciertas personas no ciudadanas no
necesiten esta prueba si están solicitando inmigración
debido a que son víctimas de violencia doméstica, testigos
para la persecución de un delito, o víctimas de trata (tráfico
con seres humanos). También es posible que no necesiten
un número de Seguro Social.
¿Cómo recibo/uso mis beneficios de CalFresh?
• El Condado le dará o le enviará por correo una tarjeta plástica de EBT (transferencia electrónica de beneficios).
Los beneficios se pondrán en la tarjeta cuando se apruebe su solicitud. Cuando llegue su tarjeta, fírmela. Para
usar su tarjeta, usted establecerá un número de identificación personal (PIN, por sus siglas en inglés).
• Si su tarjeta de EBT se pierde, se daña, o se la roban, o si usted piensa que alguien sabe su PIN y no quiere que esa
persona use sus beneficios, llame inmediatamente al (877) 328-9677 o al Condado para reportarlo y cambiar su PIN.
Asegúrese de que todos los adultos responsables y su representante autorizado también sepan cómo reportar
inmediatamente uno de estos problemas. Si usted no reporta que otra persona tiene su PIN y no quiere que esa persona
use sus beneficios pero no cambia su PIN, no se reemplazará ningún beneficio que se use.
• Usted puede usar sus beneficios de CalFresh para comprar casi todos los alimentos, al igual que semillas y plantas
para cultivar sus propios alimentos. Usted no puede comprar alcohol, tabaco, alimento para mascotas, algunos tipos
de comida ya preparada, ni cualquier otra cosa que no es comida (como pasta de dientes, jabón, o toallas de papel).
• La mayoría de las tiendas de comestibles y otros lugares que venden alimentos aceptan los beneficios de CalFresh.
Para una lista de lugares cerca de usted que aceptan la tarjeta de EBT, por favor vaya a los sitios web:
https://www.ebt.ca.gov o https://www.snapfresh.org.
• Los beneficios de CalFresh solamente son para usted y los miembros de su hogar. Mantenga seguros sus
beneficios. No dé su número de PIN a nadie. No guarde su número de PIN con su tarjeta de EBT.
¿Qué sucede si soy una persona sin hogar?
Por favor avísele inmediatamente al Condado si usted es una persona sin hogar para que le ayuden a resolver cuál
dirección usar para aceptar su solicitud y para que usted reciba notificaciones del Condado acerca de su caso. Para
CalFresh, una “persona sin hogar” significa que usted:
A. Se está quedando en un albergue supervisado, una casa de transición (halfway house), o en un lugar similar.
B. Se está quedando en el hogar de otra persona o de un familiar durante no más de 90 días consecutivos.
C. Está durmiendo en un lugar que no está designado, o normalmente no se usa, como un lugar para dormir (por
ejemplo, un pasillo, una estación de autobuses, un vestíbulo [lobby], u otros lugares similares).
Página de información - Por favor consérvela para sus expedientes.
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
p. 57
County of Orange
Bid 017-976001-GH
REGLAS Y RESPONSABILIDADES
Usted tiene la responsabilidad de:
•
•
•
•
•
•
Darle al Condado toda la información que se necesita para determinar su elegibilidad.
Darle al Condado pruebas que tenga de la información cuando se necesiten.
Reportar cambios de la manera en que se requiere. El Condado le dará información acerca de qué, cuándo, y cómo
reportar. Si usted no cumple con los requisitos que su hogar tiene para reportar, se cerrará su caso o sus beneficios
de CalFresh se reducirán o descontinuarán.
Buscar, obtener, y mantener un trabajo o participar en otras actividades, si el Condado le dice que se requiere en su caso.
Cooperar plenamente con el personal del Condado, Estado, o gobierno federal, si su caso es seleccionado para ser
revisado o investigado para asegurar que su elegibilidad y nivel de beneficios fueron determinados correctamente. El
no cooperar con estas revisiones resultará en la pérdida de sus beneficios.
Reembolsar cualquier beneficio de CalFresh que haya recibido y para el cual usted no era elegible.
Usted tiene derecho a:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Entregar una solicitud para los beneficios de CalFresh proporcionando solamente su nombre, dirección, y firma.
Tener un intérprete si lo necesita, proporcionado por el Estado sin costo para usted.
Que la información que le proporcione al Condado se mantenga confidencial, a menos que la información esté
directamente relacionada a la administración de los programas del Condado.
Retirar su solicitud en cualquier momento, antes de que el Condado determine su elegibilidad.
Pedir ayuda para completar su solicitud para beneficios de CalFresh y recibir una explicación de las reglas.
Pedir ayuda para obtener las pruebas que se necesitan.
Ser tratado con cortesía, consideración, y respecto, y no recibir ninguna discriminación.
Recibir beneficios de CalFresh antes de que pasen tres días, si es que es elegible para recibir el servicio urgente
(Expedited Service).
Ser entrevistado por el Condado en un tiempo razonable cuando usted presenta su solicitud y a que se determine su
elegibilidad antes de que pasen 30 días.
Tener al menos 10 días para darle al Condado las pruebas que se necesitan para determinar su elegibilidad.
Recibir una notificación por escrito al menos 10 días antes de que el Condado reduzca o descontinúe sus beneficios
de CalFresh.
Hablar con el Condado acerca de su caso y a revisar su caso cuando usted lo solicite.
Pedir una audiencia con el Estado antes de que pasen 90 días si no está de acuerdo con el Condado acerca de su
caso de CalFresh. Si pide una audiencia antes de que la acción para su caso de CalFresh entre en vigor, sus beneficios
de CalFresh permanecerán igual hasta que se lleve a cabo la audiencia o hasta el final de su período de certificación,
la fecha que ocurra antes. Usted puede pedirle al Condado que permita que sus beneficios cambien antes de que la
audiencia se lleve a cabo para evitar tener que reembolsar una emisión excesiva de beneficios. Si el Juez de Leyes
Administrativas emite una decisión a su favor, el Condado le devolverá los beneficios que fueron reducidos.
Pedir información acerca de sus derechos a una audiencia o una referencia para asesoramiento legal llamando al
número gratuito – 1-800-952-5253. Las personas que tienen impedimentos de audición o del habla y usan TDD (aparato
de telecomunicaciones para las personas sordas), pueden llamar al 1-800-952-8349. Es posible que pueda recibir
asesoramiento legal gratuito en la oficina local de asesoramiento legal o en la oficina de defensa de los derechos
relacionados a la asistencia pública.
Llevar a una amistad o a alguien a la audiencia, si usted no quiere ir solo.
Recibir ayuda del Condado para registrarse para votar.
Reportar cambios que no se requiere que usted reporte, si esto podría aumentar sus beneficios de CalFresh.
Dar pruebas de los gastos de su hogar que pueden ayudar a que usted reciba más beneficios de CalFresh. El no darle
pruebas al Condado es lo mismo que decir que usted no tiene ese gasto y usted no recibirá más beneficios de CalFresh.
Avisarle al Condado si a usted le gustaría que alguien más use los beneficios de CalFresh para su hogar o que le ayude
con su caso de CalFresh (representante autorizado).
Por favor conserve esta página para sus expedientes
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
p. 58
County of Orange
Bid 017-976001-GH
Reglas y sanciones del Programa
Usted está cometiendo un delito si da información falsa o errónea, o no da toda la información a propósito para tratar de
recibir beneficios de CalFresh para los cuales usted no es elegible, o para ayudar a otra persona a recibir beneficios para
los cuales no es elegible. Usted tiene que reembolsar cualquier beneficio que reciba para el cual no es elegible.
Entiendo que si yo...
Es posible que yo...
Cometo una violación intencional del Programa
haciendo alguno de los siguientes:
• Pierda los beneficios de CalFresh durante 12 meses por la
• Esconder información o hacer declaraciones falsas.
primera ofensa y se requiera que reembolse toda la
• Usar tarjetas de transferencia electrónica de beneficios
emisión excesiva de beneficios de CalFresh que recibí.
(EBT) que pertenecen a otra persona o permitir que
• Pierda los beneficios de CalFresh durante 24 meses por la
otra persona use mi tarjeta.
segunda ofensa y se requiera que reembolse toda la
• Usar beneficios de CalFresh para comprar alcohol
emisión excesiva de beneficios de CalFresh que recibí.
o tabaco.
• Pierda los beneficios de CalFresh permanentemente por la
tercera ofensa y se requiera que reembolse toda la emisión
• Cambiar, vender, o regalar los beneficios de CalFresh o
excesiva de beneficios de CalFresh que recibí.
las tarjetas de EBT.
• Reciba una multa de hasta $250,000, sea encarcelado
por hasta 20 años, o ambas cosas.
• Pierda los beneficios de CalFresh durante 24 meses por
• Cambiar beneficios de CalFresh por sustancias
la primera ofensa.
controladas, tales como drogas.
• Pierda los beneficios de CalFresh permanentemente por
la segunda ofensa.
• Dar información falsa acerca de quién soy yo y dónde • Pierda los beneficios de CalFresh durante 10 años por
cada ofensa.
vivo para poder recibir beneficios extra de CalFresh.
• Haber sido condenado por cambiar o vender beneficios • Pierda los beneficios de CalFresh permanentemente.
de CalFresh con un valor de más de $500, o cambiar
beneficios de CalFresh por armas de fuego, municiones,
o explosivos.
Información importante para las personas que no son ciudadanas
•
•
•
Usted puede solicitar y recibir beneficios de CalFresh para personas que son elegibles, aunque su familia incluya a
otros no son elegibles. Por ejemplo, padres inmigrantes pueden solicitar beneficios de CalFresh para sus hijos que
son ciudadanos de los Estados Unidos o que son inmigrantes que son elegibles, aún cuando es posible que los padres
no sean elegibles.
El recibir beneficios de un programa de asistencia alimentaria como CalFresh no le afectará a usted ni a la situación
migratoria de su familia. La información relacionada a la inmigración es privada y confidencial.
La situación migratoria de personas que no son ciudadanas que son elegibles y solicitan los beneficios se verificará
con la Oficina de Servicios de Ciudadanía e Inmigración de los Estados Unidos (USCIS, por sus siglas en inglés). La
ley federal estipula que la USCIS no puede usar la información para ninguna otra cosa excepto en casos de fraude.
Optar por no dar cierta información
Usted no tiene que dar información relacionada a la situación migratoria, números de Seguro Social, ni documentos para
aquellos miembros de la familia que no son ciudadanos y no están solicitando beneficios de CalFresh. El Condado
necesitará saber los ingresos e información sobre recursos de esas personas para determinar correctamente los beneficios
para su hogar. El Condado no se comunicará con la USCIS acerca de las personas que no soliciten beneficios de CalFresh.
Uso de los números de Seguro Social (SSN)
Todas las personas que solicitan beneficios de CalFresh necesitan proporcionar un número de Seguro Social, si tienen
uno, o pruebas de que han solicitado un SSN (tal como una carta de la Oficina del Seguro Social). El Condado puede
negar los beneficios de CalFresh para usted o para cualquier miembro de su hogar que no proporcione un SSN. Algunas
personas no tienen que dar un SSN para recibir asistencia, tales como, víctimas de abuso doméstico, testigos para la
persecución de un delito, y víctimas de trata (traficar con seres humanos).
Emisión excesiva
Esto significa que usted recibió más beneficios de CalFresh de los que debió haber recibido. Usted tendrá que
reembolsarlos aunque haya sido un error del Condado o si no fue a propósito. Sus beneficios se pueden reducir o
descontinuar. Es posible que su SSN se use para cobrar la cantidad de beneficios que debe, por medio de las cortes,
otras agencias de cobros, o una acción del gobierno federal para cobrar.
Reportes de cambios e información
Cada hogar que recibe beneficios de CalFresh tiene que reportar ciertos cambios. Su Condado le dirá qué cambios reportar
y cómo y cuándo reportarlos. El no reportar los cambios pudiera resultar en que sus beneficios de CalFresh se reduzcan
o descontinúen. Usted también puede reportar cuando ocurran cosas que pudieran aumentar sus beneficios, tales como
recibir menos ingresos.
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
p. 59
County of Orange
Bid 017-976001-GH
Audiencia con el Estado
Si no está de acuerdo con cualquier acción relacionada a su solicitud o a los beneficios que recibe, usted tiene derecho a
una audiencia con el Estado. Puede pedir una audiencia con el Estado antes de que pasen 90 días contados a partir de la
fecha de la acción del Condado y tiene que decir el motivo por el cual usted quiere una audiencia. La notificación de
aprobación o negación que reciba del Condado tendrá información sobre cómo pedir una audiencia con el Estado. Si usted
pide una audiencia antes de que la acción entre en vigor, es posible que sus beneficios de CalFresh continúen igual hasta
que se emita una decisión.
No discriminación
La práctica del Estado y del Condado es que todas las personas sean tratadas por igual, y con respecto y dignidad. De
acuerdo con la ley federal y las normas del Departamento de Agricultura de los Estados Unidos (USDA, por sus siglas en
inglés), está estrictamente prohibida la discriminación basada en la raza, color, origen nacional, sexo, edad, religión,
creencias políticas, o incapacidad/discapacidad.
Para presentar una queja de discriminación, comuníquese con el Coordinador de Derechos Civiles del Condado, o escriba
o llame a la USDA o al Departamento de Servicios Sociales de California (CDSS):
USDA, Director
Whitten Building
1400 Independence Ave., S.W.
1-202-720-5964 (voz y TDD)
CDSS
Civil Rights Bureau
P.O. BOX 944243, M.S. 8-16-70
1-866-741-6241 (Llamada gratuita)
El USDA es un empleador que ofrece oportunidades a todos por igual.
Decreto sobre la Confidencialidad y el compartir información
En la solicitud, usted está proporcionando información personal. El Condado usa la información para ver si usted es elegible
para recibir beneficios. Si usted no proporciona la información, es posible que el Condado niegue su solicitud. Usted tiene
derecho a revisar, cambiar, o corregir cualquier información que le proporcionó al Condado. El Condado no mostrará su
información ni se la dará a otros a menos que usted le de permiso o la ley federal o estatal lo permita. El Condado verificará
esta información comparándola por medio de programas de computadora, incluyendo el Sistema de Verificación de
Elegibilidad Basándose en los Ingresos (IEVS, por sus siglas en inglés). Esta información se utilizará para monitorear
cumplimiento con los ordenamientos del Programa y para la administración del Programa. Es posible que el Condado
comparta esta información con otras agencias federales y estatales para examinación federal, con oficiales encargados del
orden público con el propósito de arrestar a personas que están huyendo de la ley, y con agencias de cobro privadas para
reclamos de acción de cobro. Es posible que el Condado verifique la situación migratoria de los miembros del hogar que
están solicitando beneficios comunicándose con la USCIS. La información que el Condado reciba de estas agencias puede
afectar su elegibilidad y el nivel de beneficios.
Revisión del expediente del caso
Es posible que su caso se escoja para revisión adicional para asegurar que su elegibilidad se determinó correctamente.
Usted tiene que cooperar plenamente con el personal del Condado, Estado, y gobierno federal en cualquier investigación
o revisión, incluyendo la revisión de control de calidad. El no cooperar en estas revisiones pudiera resultar en la pérdida de
sus beneficios.
Reglas de CalFresh relacionadas al trabajo
El Condado puede asignarle a un programa de trabajo. Ellos le dirán si la participación es voluntaria o si usted tiene que
participar en el programa de trabajo. Si usted tiene una actividad de trabajo obligatoria y no la hace, es posible que sus
beneficios se reduzcan o se descontinúen.
Es posible que no sea elegible para los beneficios de CalFresh si recientemente dejó un trabajo.
Uso de la transferencia electrónica de beneficios (EBT)
No se reemplazará ningún beneficio que se haya usado de su cuenta antes de que usted, otro miembro del hogar, o su
representante autorizado, reporte que su tarjeta de EBT o su PIN (número de identificación personal) se perdió o lo robaron.
Cualquier uso de la tarjeta de EBT por usted, un miembro del hogar, su representante autorizado, o cualquier persona a
quien usted voluntariamente le haya dado su tarjeta y PIN, se considerará aprobado por usted y cualquier beneficio que se
haya tomado de su cuenta no será reemplazado.
Si no reporta que otra persona que usted no quiere que use los beneficios de usted tiene su PIN y usted no cambia su PIN,
no será reemplazado ningún beneficio que haya usado.
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County of Orange
Bid 017-976001-GH
NOTAS
CF 285 (SP) (9/13)
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p. 61
County of Orange
Bid 017-976001-GH
Por favor use tinta negra o azul porque es fácil de leer y las copias salen mejor. Escriba sus respuestas con letra de molde.
Si necesita más espacio para escribir sus respuestas, use la Página 10, Sección de “Espacio adicional para escribir” y si es
necesario, añada hojas de papel adicionales para proporcionar la información. Por favor asegúrese de identificar la pregunta a
la cual está respondiendo en el espacio extra on en las hojas de papel adicionales.
1. INFORMACIÓN DEL SOLICITANTE
NOMBRE (PRIMER NOMBRE, NOMBRE QUE USA EN MEDIO, APELLIDO)
OTROS NOMBRES (NOMBRE DE SOLTERA, APODOS, ETC.) NÚMERO DE SEGURO SOCIAL (SI LO TIENE
Y SI ESTÁ SOLICITANDO BENEFICIOS)
DIRECCIÓN DEL HOGAR O INSTRUCCIONES SOBRE CÓMO LLEGAR A SU HOGAR
CIUDAD
ESTADO
CÓDIGO POSTAL
DIRECCIÓN PARA RECIBIR EL CORREO (SI ES DIFERENTE A LA DIRECCIÓN QUE APARECE ARRIBA)
CIUDAD
ESTADO
CÓDIGO POSTAL
NÚMERO DE TELÉFONO EN EL HOGAR
DIRECCIÓN DE CORREO ELECTRÓNICO (EMAIL)
NÚMERO DE TELÉFONO EN EL TRABAJO/ALTERNATIVO/PARA MENSAJES
Quiero recibir mensajes acerca de mi caso en mi email.
■
Sí
■
No
¿Es usted una persona sin hogar? ■ Sí ■ No
Si la respuesta es “Sí”, por favor comuníqueselo al Condado para que le ayuden
a resolver cuál dirección usar para aceptar su solicitud y recibir notificaciones del Condado acerca de su caso.
¿Qué idioma prefiere leer (si no es el inglés)? ____________________________
¿Qué idioma prefiere hablar (si no es el inglés)? __________________________
El Condado le proporcionará un interprete sin costo para usted. Si usted es una persona sorda o tiene problemas de audición, por
favor marque aquí ■
¿Tiene una incapacidad/discapacidad y necesita ayuda para presentar una solicitud?
■
Sí
■
No
¿Está interesado en solicitar beneficios de Medi-Cal (Programa de Asistencia Médica de California)? Si su respuesta
es “Sí”, el Condado usará sus respuestas para ver si puede recibir Medi-Cal.
■
Sí
■
No
¿Son los ingresos brutos mensuales de su hogar menos de $150 y el dinero que tiene en efectivo, o en una cuenta
de cheques o de ahorros, es $100 o menos?
■
Sí
■
No
¿Es la combinación de los ingresos brutos mensuales de su hogar y el dinero que tiene en efectivo, o en una cuenta de
cheques o de ahorros, menos que la combinación del costo de la renta/hipoteca y servicios públicos y municipales?
■
Sí
■
No
¿Es su hogar un hogar de trabajadores migrantes o campesinos de temporada con recursos que son o se pueden convertir en
dinero en efectivo que no son más de $100 y sus ingresos se descontinuaron o no recibirá más de $25 en los siguientes 10 días?
■
Sí
■
No
Entiendo que al firmar esta solicitud bajo pena de perjurio (hacer declaraciones falsas), declaro que:
• He leído, o alguien me leyó, la información en esta solicitud y mis respuestas a las preguntas en esta solicitud.
• Mis respuestas a las preguntas son verdaderas y completas según mi leal saber y entender.
• Las respuestas que dé para el proceso de mi solicitud serán correctas y verdaderas según mi leal saber y entender.
• He leído, o alguien me leyó, entiendo y estoy de acuerdo con los “Derechos y responsabilidades” en la Página 1 de las reglas para
el Programa de CalFresh (Program Rules Page 1).
• He leído, o alguien me leyó, las “Reglas y sanciones” del Programa de CalFresh en las Páginas 2 y 3 de las reglas para el Programa
(Program Rules Pages 2 - 3).
• Entiendo que es fraude el dar declaraciones falsas o engañosas, o falsificar, esconder o retener información para establecer
elegibilidad para CalFresh. El fraude puede ocasionar que se presente un caso criminal en mi contra y/o es posible que sea excluido
de recibir beneficios de CalFresh durante un período de tiempo (o de por vida).
• Entiendo que los números de Seguro Social o la situación migratoria de los miembros de mi hogar que están solicitando beneficios
pueden ser compartidos con las oficinas/agencias del gobierno apropiadas, como lo requiere la ley federal.
FIRMA DEL SOLICITANTE (O MIEMBRO ADULTO DEL HOGAR/REPRESENTANTE AUTORIZADO*/TUTOR LEGAL)
FECHA
*Si usted tiene un representante autorizado, por favor complete la Pregunta 2 en la siguiente página.
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p. 62
County of Orange
Bid 017-976001-GH
2. REPRESENTANTE AUTORIZADO DEL HOGAR
Usted puede autorizar a alguien que tenga 18 años de edad o más para que le ayude a su hogar en lo relacionado a los beneficios de
CalFresh. Esta persona también puede hablar a nombre de usted en la entrevista, ayudarle a completar los formularios, hacer compras,
y reportar cambios a nombre de usted. Usted tendrá que reembolsar cualquier beneficio que reciba por error debido a la información
que esta persona le proporcione al Condado y no se reemplazará ningún beneficio que usted no quería que esta persona usara. Si
usted es un representante autorizado, necesitará proporcionarle al Condado pruebas de identidad para usted y para el solicitante.
¿Quiere nombrar a alguien para que le ayude con su caso de CalFresh?
Si la respuesta es “Sí”, complete la siguiente sección:
■
NOMBRE DEL REPRESENTANTE AUTORIZADO
Sí
■
No
NÚMERO DE TELÉFONO DEL REPRESENTANTE AUTORIZADO
¿Quiere nombrar a alguien para que reciba y utilice los beneficios de CalFresh para su hogar?
Si la respuesta es “Sí”, complete la siguiente sección:
NOMBRE:
■
Sí
■
No
NÚMERO DE TELÉFONO:
DIRECCIÓN:
CIUDAD
ESTADO
CÓDIGO POSTAL
3. RAZA/ETNIA
La información sobre la raza y etnia es opcional. Se solicita para asegurar que los beneficios se proporcionen sin tomar en consideración
la raza, color, u origen nacional. Sus respuestas no afectarán su elegibilidad ni la cantidad de sus beneficios. Marque todo lo que sea
pertinente para usted. La ley estipula que el Condado tiene que registrar su grupo étnico y raza.
■
Marque esta casilla si usted no quiere proporcionarle al Condado información acerca de su raza y etnia. Si usted no lo hace, el
Condado anotará esta información solamente para estadísticas relacionadas a los derechos civiles.
Si es de origen hispano o latino, se considera usted:
ETNIA
¿Es usted hispano o latino?
■
Sí
■
No
■ Mexicano ■ Puertorriqueño ■ Cubano
■ Otro _________________________________________________
RAZA/ORIGEN ÉTNICO
■ Blanco
■ Indio (indígena de los Estados Unidos
■
■ Negro o afroamericano ■ Otro o mixto ____________________
de América) o Indígena de Alaska
Asiático (Si marca esta casilla, por favor seleccione uno o más de los siguientes):
■
Indígena hawaiano u otro isleño del Pacífico (Si marca esta casilla, por favor seleccione uno o más de los siguientes):
■ Filipino ■ Chino ■ Japonés ■ Camboyano
■ Otro asiático (especifique) __________________
■
Indígena hawaiano
■
Guameño o chamorro
■
■ Coreano
■ Vietnamita
■ Hindú
■ Laosiano
Samoano
4. PREFERENCIA EN LO RELACIONADO A LA ENTREVISTA
Usted necesitará tener una entrevista con el Condado para hablar acerca de su solicitud y para recibir beneficios de CalFresh. Las
entrevistas para CalFresh por lo general se llevan a cabo por teléfono, a menos que la entrevista se pueda llevar a cabo cuando entregue
su solicitud en persona al Condado o si usted prefiere tener una entrevista en persona. La entrevista en persona solamente se llevará a
cabo durante horas normales de oficina del Condado.
■
■
Por favor marque esta casilla si usted prefiere una entrevista en persona.
Por favor marque esta casilla si usted necesita otros arreglos debido a una incapacidad/discapacidad.
Por favor marque las casillas a continuación para indicar su preferencia para el día y hora de su entrevista.
Día:
Hora:
■ Hoy ■ Próximo día disponible ■ Cualquier día ■ Lunes ■ Martes ■ Miércoles ■ Jueves ■ Viernes
■ Temprano en la mañana ■ A media mañana ■ A mediodía ■ Tarde después del mediodía ■ A cualquier hora
5. OTROS PROGRAMAS
¿Alguien en su hogar alguna vez ha recibido asistencia pública (Asistencia Temporal para Familias Necesitadas, conocida en inglés como
“Temporary Assistance for Needy Families - TANF”; Medicaid - asistencia médica en otro estado; Programa de Asistencia para Nutrición
Suplemental, conocido en inglés como “Supplemental Nutrition Assistance Program - SNAP” [estampillas para comida]; Asistencia General
- GA/Ayuda General - GR, etc.)?
■ Sí ■ No
SI LA RESPUESTA ES “SÍ”, ¿QUIÉN LA RECIBIÓ?
¿EN DÓNDE? (CONDADO/ESTADO)
SI LA RESPUESTA ES “SÍ”, ¿QUIÉN LA RECIBIÓ?
¿EN DÓNDE? (CONDADO/ESTADO)
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County of Orange
Bid 017-976001-GH
6a. INFORMACIÓN DEL HOGAR
Complete la siguiente información para todas las personas en el hogar con las que usted
compra y prepara alimentos; incluyendo a usted mismo. Si está solicitando beneficios
para personas que no son ciudadanas, por favor complete las Preguntas 6b y 6c.
Si no, vaya a la Pregunta 6d.
BENEFICIOS
QUE ESTÁ
SOLICITANDO
(✔ Marque
“Sí” o “No”)
NOMBRE
(Apellido, primer nombre,
inicial del nombre que usa en medio)
¿Qué
FECHA DE
relación/
parentesco NACIMIENTO
tiene con
usted?
El número de Seguro Social es opcional para los
miembros que no están solicitando beneficios.
Tiene que contestar las siguientes preguntas para
cada persona que está solicitando beneficios.
CIUDADANO O
NACIONAL DE
LOS ESTADOS
UNIDOS
(✔ Marque
SEXO
“Sí” o “No”)
(M o F) Si la respuesta es
“No”, complete la
Pregunta 6b
abajo
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
NÚMERO DE
SEGURO SOCIAL
Por favor anote el nombre de cualquier persona que vive con usted que no compra ni prepara alimentos con usted.
NOMBRE
NOMBRE
NOMBRE
NOMBRE
6b. INFORMACIÓN DE LAS PERSONAS QUE NO SON CIUDADANAS - Complete para aquellos anotados en la Pregunta 6a arriba
que no son ciudadanos y están solicitando beneficios.
¿Patrocinado?
Fecha en
Anote uno de los siguientes (si lo sabe):
(✔ Marque “Sí” o “No”)
que entró a
Si la respuesta es
Número de pasaporte,
Nombre
los EE. UU.
“Sí”, complete la
Número
de
tarjeta
de
residente
legal,
etc.
(Si la sabe)
Pregunta 6c abajo
TIPO DE DOCUMENTO: ____________________________________________
NÚMERO DEL DOCUMENTO: ________________________________________
¿Alguien que aparece anotado anteriormente tiene al menos 10 años (40 trimestres) de historial de trabajo o servicio militar en los EE. UU.?
Si la respuesta es “Sí”, ¿quién? ___________________________________________
¿Alguien que aparece anotado anteriormente tiene o ha solicitado, o tiene planes de solicitar una T-visa (Visa de estatus de no inmigrante por
ser víctima de trata de personas (tráfico con seres humanos), conocida en inglés como “Victims of Human Trafficking: T nonimmigrant status” );
U-visa (Visa de estatus de no inmigrante que proporciona un estatus legal temporal a personas que no son ciudadanas pero son víctimas de
violencia doméstica o de un crimen o están ayudando o están dispuestas a ayudar a las autoridades en la investigación de crímenes. Esta visa
es conocida en inglés como “U nonimmigrant status” ); o presentar una petición VAWA (Petición bajo el Decreto contra la Violencia
hacia las Mujeres, conocido en inglés como “Violence Against Women Act” )?
Si la respuesta es “Sí”, ¿quién? ___________________________________________
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
■
Sí ■ No
6c. INFORMACIÓN DE LA PERSONA NO CIUDADANA PATROCINADA - Complete para aquellas personas anotadas arriba en la
Pregunta 6b quienes son personas no ciudadanas patrocinadas y están solicitando asistencia.
¿Firmó el patrocinador una I-864 (Declaración jurada de apoyo)? ■ Sí ■ No Si la respuesta es “Sí”, por favor conteste el
resto de la pregunta. Si el patrocinador firmó una I-134, vaya a la siguiente pregunta.
¿Ayuda el patrocinador regularmente con dinero? ■ Sí ■ No Si la respuesta es “Sí”, ¿cuánto? $ _________
¿Ayuda el patrocinador regularmente con alguno de los siguientes? Marque todos los que sean pertinentes.
■ Renta ■ Ropa ■ Alimentos
■ Otro __________________________________________________
NOMBRE DEL PATROCINADOR
¿QUIÉN ESTÁ PATROCINADO?
TELÉFONO DEL PATROCINADOR
NOMBRE DEL PATROCINADOR
¿QUIÉN ESTÁ PATROCINADO?
TELÉFONO DEL PATROCINADOR
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County of Orange
Bid 017-976001-GH
6d. Estudiantes
¿Alguna persona que está solicitando beneficios está yendo a un colegio universitario (college) o a
una escuela vocacional? ■ Sí ■ No
Si la respuesta es “Sí”, por favor conteste esta pregunta. Si la respuesta es “No”, vaya a la siguiente pregunta.
Inscrito
¿Trabajando?
Nombre de la escuela/entrenamiento
Nombre de la persona
(✔ marque uno)
■
■
Medio tiempo o más
Menos de medio tiempo
■
■
Medio tiempo o más
Menos de medio tiempo
Promedio de horas
de trabajo a la
Número de unidades: _____ semana: _______
Promedio de horas
de trabajo a la
Número de unidades: _____ semana: _______
6e. ¿Está un niño bajo cuidado de crianza temporal (foster care) viviendo en su hogar?
Si la respuesta es “Sí”, ¿quién?______________________________________
Por favor conteste las siguientes preguntas acerca del niño(s) bajo cuidado de crianza temporal:
¿Colocaron a este niño(s) en su hogar por una orden del tribunal encargado de poner a un menor bajo
la tutela de la corte (dependency order)?
¿Quiere que el niño(s) bajo cuidado de crianza temporal se cuente en su caso de CalFresh? Si la
respuesta es “Sí”, los ingresos provenientes del cuidado de crianza temporal que usted reciba se
contarán como ingresos no ganados. Si la respuesta es “No”, los ingresos provenientes del cuidado
de crianza temporal no se contarán como ingresos no ganados.
7.
Ingresos no ganados
¿Alguien con quien usted compra y prepara alimentos recibe ingresos que no provienen de un empleo
(ingresos no ganados)?
A continuación marque todas las clases de ingresos no ganados que sean pertinentes (es posible que otras clases
no estén incluidas aquí):
■
■
■
■
Seguro Social
SSI/SSP (Ingresos Suplementales
de Seguridad/Pagos
Suplementarios del Estado)
Asistencia monetaria
CalWORKs (Programa de
California de Oportunidades de
Trabajo y Responsabilidad hacia
los Niños) / TANF (Asistencia
Temporal para Familias
Necesitadas) / GA/GR (Asistencia
General/Ayuda General) / CAPI
(Programa de Asistencia
Monetaria para Inmigrantes)
Persona que está
recibiendo el dinero
■
■
■
■
■
■
■
Alimentos y hospedaje (room and
board) (de un arrendador)
■
■
Pensión
Mantenimiento de hijos/esposa(o)
Beneficios por incapacidad/
discapacidad o jubilación del
gobierno o del ferrocarril
Beneficios para veteranos o
pensión militar
Asistencia financiera
(subvenciones/préstamos/
becas escolares)
Regalos de dinero
■
■
■
■
■
■
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
Seguro de Desempleo/SDI (Seguro del
Estado contra Incapacidad)
Compensación por lesiones de trabajo
(Worker’s Compensation)
Premios de lotería/juego (gambling)
Ayuda con la renta/alimentos/ropa
Pagos de seguro o pagos por arreglos
legales
Pagos privados por incapacidad/
discapacidad o jubilación
Beneficios por huelga
Otro ____________________
________________________
¿De dónde?
¿Cuánto?
¿Con qué frecuencia lo recibe? ¿Espera que
continúe?
(Una sola vez, semanalmente,
(Marque Sí o No)
mensualmente, u otro)
$
■ Sí ■ No
$
■ Sí ■ No
$
■ Sí ■ No
$
■ Sí ■ No
Si no espera que estos ingresos continúen, por favor explique:
CF 285 (SP) (9/13)
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County of Orange
8.
Bid 017-976001-GH
Ingresos ganados
¿Alguien recibe ingresos de un empleo (ingresos ganados)? ■ Sí ■ No
Si la respuesta es “Sí”, por favor conteste esta pregunta. Si la respuesta es “No”, vaya a la Pregunta 9.
NOTA: Si tiene un trabajo por cuenta propia, conteste la Pregunta 8a.
Por favor anote todos los ingresos antes de los impuestos u otras deducciones (ingresos brutos).
Estos son ejemplos de ingresos ganados (estos ejemplos pueden ser trabajo de tiempo completo, temporal, o de temporada, o
pueden ser entrenamiento, y es posible que haya otros que no estén mencionados aquí):
●
●
● Propinas
●
●
Sueldo
Comisiones
Salarios
Trabajo-estudio (estudiantes)
Persona que trabaja
Nombre y dirección
del empleador
Número de
teléfono del
empleador
¿Con qué
Total de
¿Espera
frecuencia le
ingresos
que
Pago
Promedio
pagan?
ganados continúen?
por hora de horas
(Una vez a la
brutos
(✔ Marque
por
semana,
recibidos Sí o No)
semana mensualmente, otro)
este mes
$
$
■ Sí
■ No
$
$
■ Sí
■ No
$
$
■ Sí
■ No
$
$
■ Sí
■ No
Si no espera que estos ingresos continúen, por favor explique:
En los últimos 60 días, ¿alguien ha perdido, cambiado, o dejado un trabajo, o ha reducido sus horas de trabajo?
SI LA RESPUESTA ES “SÍ”, ¿QUIÉN?
■ Sí ■ No
FECHA DE LA PÉRDIDA O CAMBIO O CUANDO DEJÓ EL TRABAJO FECHA DEL ÚLTIMO DÍA DE PAGO
MOTIVO
¿Alguien está en huelga?
■
Sí
■ No
FECHA EN QUE SE PUSO EN HUELGA
FECHA DEL ÚLTIMO DÍA DE PAGO
MOTIVO
8a. Trabajo por cuenta propia
Los miembros de un hogar que trabajan por cuenta propia pueden deducir los gastos verdaderos del trabajo por cuenta propia o una
deducción estándar del 40% de los ingresos provenientes del trabajo por cuenta propia. Si escoge los gastos verdaderos, necesitará
darle al Condado pruebas de los gastos.
Persona que trabaja
por cuenta propia
Fecha cuando
empezó el negocio
Tipo de negocio y nombre
Ingresos brutos Gastos del trabajo por cuenta propia
mensuales
(Por favor ✔ marque uno)
$
$
$
$
$
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
■
■
■
■
■
■
■
■
■
■
Estándar del 40%
Gastos verdaderos $ _________
Estándar del 40%
Estándar del 40%
Estándar del 40%
Estándar del 40%
PAGE 5 OF 10
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County of Orange
9.
Bid 017-976001-GH
Gastos para el cuidado de niños/adultos en el hogar
¿Paga usted, o alguien que compra y prepara alimentos con usted, para el cuidado de un niño, adulto incapacitado/
discapacitado u otros dependientes para que usted u otra persona pueda ir a trabajar, a la escuela, o a buscar un empleo?
¿Quién proporciona el cuidado?
(Nombre y dirección del proveedor)
¿Quién recibe el cuidado?
Cantidad
pagada
■ Sí ■
No
¿Con qué frecuencia se paga?
(semanalmente/mensualmente, otra)
$
$
$
$
¿Alguien le ayuda a su hogar a pagar todo o parte del costo del cuidado de niños/adultos anotados arriba?
Si la respuesta es “Sí”, complete la información a continuación.
¿Quién recibe el cuidado?
Cantidad
pagada
¿Quién ayuda a pagar?
■ Sí ■
No
$
$
10. Pagos de mantenimiento de hijos
¿Está usted, o alguien que compra y prepara alimentos con usted, legalmente obligado a pagar mantenimiento de hijos,
incluyendo pagos atrasados de mantenimiento de hijos? ■ Sí ■ No
¿Quién paga
el mantenimiento de hijos?
Cantidad
pagada
Nombre del niño(s) para quien se paga
el mantenimiento de hijos
$
$
11. Gastos del hogar
¿Es usted, o alguien que compra y prepara alimentos con usted, responsable por alguno de los gastos del hogar?
NOTA: No anote cantidades pagadas de asistencia para la vivienda, tales como HUD (Departamento de la
Vivienda y el Desarrollo Urbano) o la Sección 8. El servicio para calentar y enfriar, el servicio de teléfono, otros
servicios públicos y municipales, y el alojamiento para personas sin hogar son deducciones ya establecidas. No
es necesario anotar la cantidad verdadera que se tiene que pagar.
Tipo de gastos
Renta o pago de casa
Impuestos y seguro de la propiedad
(Si es separado de la renta o hipoteca)
¿Tiene
el gasto?
■ Sí ■ No
■ Sí ■ No
Teléfono/teléfono celular
■ Sí ■ No
Gasto de alojamiento para personas
sin hogar
■ Sí ■ No
Agua, alcantarillado, basura
■ Sí ■ No
■ Sí ■ No
Si la respuesta es “Sí”, por favor complete
Cantidad que ¿Con qué frecuencia
le cobran?
tiene que pagar
(semanalmente/mensualmente)
$
$
■ Sí ■ No
Gas, electricidad, u otro combustible para
calentar o enfriar, tal como leña o propano
(Si es separado de la renta o hipoteca)
¿Alguien que no está en su hogar le ayuda a
pagar los gastos anotados anteriormente?
¿Quién paga?
■ Sí ■ No
¿Quién ayuda a pagar?
¿Cuánto?
¿Con qué
frecuencia se paga?
$
¿Recibe su hogar, o espera recibir algún pago del Programa de Asistencia para Pagar Gastos de Energía para Personas de Bajos
Ingresos, conocido en inglés como “Low Income Home Energy Assistance Program” (LIHEAP)? ■ Sí ■ No
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
PAGE 6 OF 10
p. 67
County of Orange
Bid 017-976001-GH
12. Gastos médicos
¿Es usted, o alguien con quien compra y prepara alimentos, una persona de edad avanzada (60 años o más) o una persona
incapacitada/discapacitada que tiene gastos médicos que tiene que pagar de su bolsa? ■ Sí ■ No
NOTA: No anote a un esposo(a) o niños que reciben pagos de dependiente de un beneficiario que recibe Ingresos Suplementales
de Seguridad (SSI) o pagos por incapacidad/discapacidad y ceguera. Anote los gastos que espera tener en un futuro cercano.
Los gastos médicos que se permiten son:
■
■
■
■
■
■
Cuidado médico o dental
Hospitalización/tratamiento
externo/cuidado de enfermería
Medicinas recetadas
Primas de pólizas de seguro de
salud y hospitalización
Primas de Medicare (parte del
costo de Medi-Cal, etc.)
■
■
■
Nombre de la
persona de edad avanzada/
incapacitada/discapacitada
Dentaduras, aparatos para oír
y prótesis
Mantenimiento para un asistente
necesario por edad avanzada,
enfermedad, o dolencias
Número y costo de comidas
proporcionadas a un asistente
Medicinas recomendadas que no
necesitan receta
Cantidad
del gasto
■
■
■
■
¿Con qué frecuencia ¿Qué tipo de gasto?
se paga?
(recetas, dentaduras,
# de comidas por
(mensualmente,
asistente, etc.)
semanalmente, otra)
Costo de transporte (millage o cuota) y
alojamiento para obtener tratamiento o
servicios médicos
Lentes y lentes de contacto recetados
Equipo y suministros médicos
recetados
Gastos de animales de servicio
(alimento, facturas del veterinario, etc.)
¿Recibirá el hogar un reembolso
por algún gasto médico?
(de Medi-Cal, seguro,
miembro de la familia, etc.)
SI LA RESPUESTA ES “SI”, ¿POR QUIÉN?
$
¿CUÁNTO? $
$
¿CUÁNTO? $
$
¿CUÁNTO? $
$
¿CUÁNTO? $
13. ¿Alguien recibe alimentos de alguno de los siguientes? ■ Sí ■ No
●
Servicio de comedor comunitario para las
●
Programa de distribución de alimentos
●
Otro programa
personas de edad avanzada o
operado por una reservación de
de alimentos
incapacitadas/discapacitadas
indígenas de los EE. UU. de América
¿DÓNDE?
¿DÓNDE?
14. ¿Alguien vive en alguno de los siguientes? ■ Sí ■ No
●
Albergue para personas sin hogar
●
Vivienda subsidiada por el gobierno federal
●
Albergue para mujeres maltratadas
●
Hospital psiquiátrico/Institución mental
●
Reservación para indígenas de los EE. UU. de América
●
Hospital
●
Centro de rehabilitación para drogadictos/alcohólicos
●
Establecimiento de cuidado a largo plazo u hospedaje y
●
Centro penitenciario/Institución penal (cárcel o prisión)
cuidado (Long-Term Care o Board and Care Facility)
●
Vivienda colectiva para ciegos/incapacitados/discapacitados
Nombre de la persona
Nombre de la institución (Centro, albergue, establecimiento, etc.)
Fecha en que espera salir
(si es pertinente)
15. ¿Alguien que vive con usted tiene 60 años de edad o más y no puede comprar alimentos ni preparar
comidas por separado debido a una incapacidad/discapacidad?
■
Sí
■ No
CF 285 (SP) (9/13)
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PAGE 7 OF 10
p. 68
County of Orange
16.
Bid 017-976001-GH
Recursos del hogar
¿Tiene usted, o alguien que compra y prepara alimentos con usted, recursos (dinero en efectivo, dinero en el banco, certificados de
depósito, acciones o bonos, etc.)? ■ Sí ■ No
A continuación, marque cada recurso que usted o alguien en el hogar tiene:
Cuenta (de cheques) en un banco/unión de crédito ■ Cuenta(s) bancaria de inversión en el
mercado de valores (Money Market Account)
Cuenta (de ahorros) en un banco/unión de crédito
■ Fondos mutualistas (Mutual funds)
Caja de seguridad (Safe Deposit box)
■ Certificados de depósito (CD)
Bono(s) de ahorro
■ Dinero en efectivo a la mano
■
■
■
■
■
■
■
Acciones
Bonos
Otro: ____________________
Si es una cuenta conjunta con otra persona, por favor indíquelo a continuación.
Para cada casilla que marcó anteriormente, complete la siguiente información.
¿A nombre de quién está
registrado el recurso?
Tipo de recurso
¿Cuánto vale?
¿En dónde está el recurso?
(Incluya el nombre del banco o compañía donde está el dinero)
$
$
$
$
En los últimos tres (3) meses, ¿ha usted, o alguien en su hogar, vendido, cambiado, regalado, o transferido
algún recurso?
17.
18.
19.
20.
21.
22.
Beneficios duplicados
¿Ha sido usted, o algún miembro de su hogar, declarado culpable de haber recibido fraudulentamente
beneficios duplicados de SNAP (Programa Federal de Asistencia para Nutrición Suplemental conocido como
“CalFresh” in California) en algún estado después del 22 de septiembre, 1996?
Si la respuesta es “Sí”, ¿quién? _________________________________________________________
Traficar beneficios
¿Alguna vez ha sido usted, o algún miembro de su hogar, declarado culpable de traficar beneficios de SNAP
(permitir el uso o vender tarjetas de EBT a otros) con un valor de $500 o más después del 22 de septiembre, 1996?
Cambiar beneficios por drogas
¿Ha sido usted, o algún miembro de su hogar, declarado culpable de cambiar beneficios de SNAP por drogas
después del 22 de septiembre, 1996?
Cambiar beneficios por armas o explosivos
¿Ha sido usted, o algún miembro de su hogar, declarado culpable de cambiar beneficios de SNAP por armas
de fuego, municiones o explosivos después del 22 de septiembre, 1996?
Criminal huyendo de la ley
¿Está usted, o algún miembro de su hogar, escondiéndose o huyendo de la ley para evitar enjuiciamiento, ser
puesto bajo custodia, o ir a la cárcel por cometer o atentar cometer un delito mayor (felony) ?
Violación de la libertad condicional (probation/parole)
¿Ha sido usted, o algún miembro de su hogar, declarado culpable por una corte de violar
su libertad condicional (probation o parole) ?
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
■ Sí ■ No
PAGE 8 OF 10
p. 69
County of Orange
23.
Delito mayor (felony) por drogas
¿Ha sido usted, o un algún miembro de su hogar, declarado culpable de un delito mayor (felony) por
tener, usar, o distribuir una sustancia controlada (drogas ilegales o ciertas drogas para la cuales se
requiere una receta médica) después del 22 de agosto, 1996?
Si la respuesta es “Sí”, y la condena por delito mayor (felony) fue por posesión, ¿ha hecho (o lo hará)
usted, o ese miembro del hogar, alguno de los siguientes?:
Bid 017-976001-GH
■ Sí ■ No
b) ¿Participó en un programa reconocido por el gobierno para el tratamiento de drogadictos?
■ Sí ■ No
■ Sí ■ No
c) ¿Se inscribió en un programa reconocido por el gobierno para el tratamiento de drogadictos?
■ Sí ■ No
d) ¿Está en una lista de espera para un programa reconocido por el gobierno para el
tratamiento de drogadictos?
■ Sí ■ No
e) ¿Dejó de usar sustancias controladas y tiene evidencias de que las ha dejado de usar?
■ Sí ■ No
a) ¿Completó un programa reconocido por el gobierno para el tratamiento de drogadictos?
Si la respuesta es “Sí”, por favor explique: ______________________________________________
_______________________________________________________________________________________
Espacio adicional para escribir
CF 285 (SP) (9/13)
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PAGE 9 OF 10
p. 70
County of Orange
Bid 017-976001-GH
Espacio adicional para escribir
NO LLENAR. SÓLO PARA USO DEL CONDADO (COUNTY USE ONLY)
■ Yes ■
No
Is the household’s combined gross income and cash on hand or in checking and savings accounts
■ Yes ■
No
■ Yes ■
No
CF 285 (SP) (9/13)
11/19/2013 11:22 AM
PAGE 10 OF 10
p. 71
County of Orange
Bid 017-976001-GH
Si no está inscrito para votar donde vive ahora, ¿quiere solicitar su inscripción para votar hoy aquí?
(Marque uno)
Ya estoy inscrito.
Estoy inscrito para votar en mi dirección residencial actual.
Sí.
Me quiero inscribir para votar. (Llene la tarjeta adjunta de inscripción para votar.)
No.
No me quiero inscribir para votar.
NOTA: SI NO MARCA UNA CASILLA, SE CONSIDERARÁ QUE HA DECIDIDO NO INSCRIBIRSE PARA VOTAR EN
ESTE MOMENTO. PUEDE LLEVAR EL FORMULARIO DE SOLICITUD DE INSCRIPCION PARA VOTAR
ADJUNTO E INSCRIBIRSE CUANDO LE SEA CONVENIENTE.
___________________________________________________________________
Nombre del solicitante
Fecha
Avisos importantes
1. Si solicita su inscripción para votar, o decide no hacerlo, ello no afectará la cantidad de ayuda provista por esta agencia.
2. Si necesita ayuda para llenar el formulario de solicitud de inscripción para votar, lo ayudaremos a hacerlo. La decisión de
solicitar o aceptar ayuda es sólo suya. Puede llenar el formulario de solicitud en privado.
3. Si cree que alguien interfirió con su derecho a inscribirse para votar, o a no inscribirse, su derecho a privacidad para
decidir si se inscribe o solicita inscribirse para votar, o su derecho a elegir el partido político u otra preferencia política,
puede presentar una queja ante el Secretario de Estado llamando sin cargo al (800) 232-VOTA (8682), o escribiendo a:
Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. Para obtener más información sobre las elecciones y la
votación, visite el sitio web del Secretario de Estado en www.sos.ca.gov.
01/13 NVRA Voter Preference Form – Spanish
11/19/2013 11:22 AM
p. 72
County of Orange
Bid 017-976001-GH
¿SABIA USTED?
Que Su Familia Podría Calificar Para Medi-Cal
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UHFXUVRVOLPLWDGRV
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REWHQHUFREHUWXUDGHQWDO\YLVLyQJUDWXLWDDWUDYpVGHOSURJUDPGH0HGL&DO
i 6LXVWHGRDOJXQPLHPEURGHVXIDPLOLD\DWLHQHQ0HGL&DOQRQHFHVLWDUHJUHVDU
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'R\SHUPLVRDO&RQGDGRGH2UDQJHSDUDTXHXVHODLQIRUPDFLyQGLVSRQLEOHHQPLDUFKLYRGH(VWDPSLOODVGH
&RPLGDSDUDGHWHUPLQDUVLPLIDPLOLDFDOLILFDSDUD0HGt&DO6t
1R <RKHOHtGR\HQWLHQGRORVGHUHFKRV\ODVUHVSRQVDELOLGDGHVTXHDSDUHFHQDORWURODGRGHHVWHIRUPXODULR6t
1R )LUPDBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB )HFKDBBBBBBBBBBBBBBBBBBBBBBB
6LKD\XQQLxRHQHOKRJDUVHUHTXLHUHODILUPDGHOSDGUHRHOWXWRU
1RPEUHHQ/HWUDGH0ROGHBBBBBBBBBBBBBBBBBBBBBBB)HFKDGH1DFLPLHQWRBBBBBBBBBBBBBBB
'RPLFLOLRBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
1~PHURGH7HOpIRQRBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
$OJXLHQHQPLIDPLOLDWLHQHVHJXURGHVDOXGRKDWHQLGRVHJXURGHVDOXGHQORV~OWLPRV
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6t 1R 8VWHGSXHGHFRQWHVWDU³6t´\D~QVHUHOHJLEOH
6LWLHQHSUHJXQWDVRQHFHVLWDD\XGDSRUIDYRUOODPHD
AVISO DE CONFIDENCIALIDAD DE MEDI-CAL:
Los Artículos 10850 y 14100.2 del Código de Beneficencia e Instituciones (Welfare and Institutions Code) establecen que la
información que se proporciona en esta solicitud es confidencial y privada. La información se podrá revelar sólo en conformidad
con esas leyes.
)635HY
11/19/2013 11:22 AM
p. 73
County of Orange
Bid 017-976001-GH
DECLARACIONES, DERECHOS Y RESPONSABILIDADES DE MEDI-CAL:
Tengo derecho a:
x Ser tratado con decencia e igualdad, sin importar mi raza, color, religión, origen nacional, género, edad o creencia política.
x Solicitar un intérprete.
x Solicitar una audiencia imparcial si considero que una decisión relacionada con mi caso de Medi-Cal es injusta o incorrecta.
Debo solicitar una audiencia dentro de los 90 días después de haber recibido una Notificación de Acción. Para información
sobre audiencias imparciales de Medi-Cal, llame gratis al 1-800-952-5253.
Tengo las siguientes responsabilidades:
x Mandar al condado un informe de ajuste cuando éste lo solicite.
x Notificar dentro de un plazo de 10 días cualquier cambio en la información que estoy dando en esta solicitud.
x Notificar al condado si un miembro de mi familia solicita beneficios por incapacidad, vive en una institución pública o si
recibe atención médica por algún accidente o lesión provocada por otra persona.
x Cooperar si mi caso es revisado.
Declaro que cada persona para quien solicito beneficios:
x Tiene que vivir en California.
x No tiene que recibir asistencia pública fuera de California.
x No tiene que estár en la cárcel, la prisión ni en ninguna otra institución correccional.
Asimismo declaro que:
x Como condición de mi elegibilidad para Medi-Cal, comprendo que todos los derechos a recibir asistencia médica se asignan
automáticamente al estado de California.
x Si no soy elegible para este programa de Medi-Cal, comprendo que es posible que califique para otros programas y tengo
derecho a solicitarlos.
x Comprendo que si intencionalmente no doy información necesaria o si doy información falsa, se me pueden negar
beneficios o estos pueden ser anulados o se me podrá requerir que reembolse el pago de dichos beneficios. Asimismo,
podré ser investigado por fraude.
AVISO DE PRIVACIDAD DE MEDI-CAL:
La Ley de Prácticas de Información de 1977 y la Ley Federal sobre Privacidad requieren que el Departamento de Servicios para
la Salud informe lo siguiente: El Artículo 14011 del Código de Beneficencia e Instituciones y las normas incluidas en el Título 22
del Código de Normas de California (CCR), establecen que las personas que solicitan inscribirse en el programa Medi-Cal deben
entregar la información sobre elegibilidad que requiere esta solicitud. Esta información podrá ser compartida con las agencias
federales, estatales y locales para verificar la elegibilidad y para otros fines relacionados con la administración del programa
Medi-Cal, incluyendo la confirmación con la Oficina de Ciudadanía y Servicios de Inmigración del estado inmigratorio, solamente
para aquellas personas que solicitan beneficios completos de Medi-Cal. (La legislación federal establece que la Oficina de
Ciudadanía y Servicios de Inmigración no puede utilizar la información con ningún otro propósito, excepto en casos de fraude.)
La información será utilizada por un LQWHUPHGLDULRILVFDO para procesar reclamos y para fabricar las Tarjetas de Identificación
para Beneficios (BIC). Si no se proporciona la información requerida, la solicitud de inscripción podrá ser rechazada.
Es obligatorio entregar toda la información solicitada en este formulario, excepto la información étnica y cualquier otro dato
identificado como voluntario u opcional. Los números de Seguro Social se requieren de acuerdo con el Artículo 1147(a)(1) de la
Ley de Seguro Social, y el Artículo 14011.2 del Código de Beneficencia Pública e Instituciones, a menos que se soliciten
únicamente servicios de emergencia o relacionados con el embarazo. Todas las personas tienen derecho de acceso a los
archivos con su información personal que se encuentran en poder del Departamento de Servicios para la Salud en su condado.
)635HY
11/19/2013 11:22 AM
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County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 75
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 76
County of Orange
Bid 017-976001-GH
CALFRESH BENEFITS
Reporting basis.
CHANGE REPORTING
•
•
•
•
•
•
•
•
living in the home.
employment’
week;
benefits;
• Pregnant; or
benefits.
•
•
•
•
•
•
•
•
•
Office; or
Report form.
11/19/2013 11:22 AM
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County of Orange
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Bid 017-976001-GH
p. 78
County of Orange
Bid 017-976001-GH
BENEFICIOS DE CALFRESH
CÓMO REPORTAR CAMBIOS EN EL GRUPO PARA FINES DE CALFRESH
Todos los que reciben beneficios de CalFresh tienen que presentar un reporte cuando haya cambios en sus ingresos o en
la situación de su grupo para fines de CalFresh (grupo). Si no está seguro de cómo reportar cambios, cuáles cambios tiene
que reportar, o cuáles pruebas necesitamos, asegúrese de preguntarle a su oficina local del Condado. Usted está
recibiendo esta notificación porque:
■ Usted ha sido aprobado para recibir los beneficios de CalFresh y estará reportando cambios semianualmente.
■ Anteriormente, su grupo estaba asignado a reportar cuando un cambio ocurriera y ahora estará reportando cambios semianualmente.
Los requisitos para reportar semianualmente están descritos a continuación:
REPORTES SEMIANUALES
Como grupo que reporta semianualmente, necesitará entregar
un formulario de reporte semianual (SAR 7) completado a más
tardar el día 5 del sexto mes después de su certificación más
reciente. Si no entrega su SAR 7 completado a más tardar para
el final del primer día hábil del siguiente (séptimo) mes, sus
beneficios se descontinuarán.
Para calcular sus beneficios de CalFresh para el resto del
período de certificación, su trabajador usará la información
sobre ingresos y gastos que usted reportó en el SAR 7.
Por ejemplo:
Usted completó su recertificación anual en mayo. Su SAR 7 se
tiene que entregar seis meses después, el 5 de noviembre y usted
reportará los ingresos que tuvo en octubre. También reportará
cualquier cambio en sus ingresos que usted espera tener en
diciembre, enero, febrero, marzo, abril, y mayo. Usted tiene que
entregar su SAR 7 completado a más tardar el primer día hábil en
diciembre o sus beneficios se descontinuarán. Usted perderá
beneficios a menos que tenga un motivo justificado para entregarlo
tarde. Su recertificación anual se tendrá que hacer en mayo, seis
meses después. Su próximo SAR 7 se tiene que entregar para el
siguiente período de certificación seis meses después.
Lo que tiene que reportar en el reporte semianual (SAR 7):
• Ingresos ganados de cualquier fuente;
• Cualquier clase de ingresos no ganados;
• Cualquier persona que recibe renta o servicios públicos y
•
•
•
•
•
•
•
•
•
•
•
•
municipales gratuitos;
Cualquier persona que tiene gastos que son pagados por
otra persona;
Horas reducidas de trabajo o entrenamiento;
Alguien se muda al/del hogar de usted;
Usted se muda;
Bienes raíces o bienes personales que se compran, se
venden, o se cambian;
Cualquier cambio en el mantenimiento de hijos que algún
miembro del grupo paga por obligación legal;
La situación migratoria/ciudadanía de alguien cambia o
alguien recibe correspondencia de la Oficina de Servicios
de Ciudadanía e Inmigración de los Estados Unidos
(USCIS) (antes conocida como el Servicio de Inmigración y
Naturalización [INS]);
Alguien cumple 60 años de edad;
Alguien consigue un empleo o recibe pagos por gastos
relacionados con entrenamiento o educación;
Alguien tiene gastos relacionados con un empleo,
entrenamiento, o educación; por ejemplo, para el cuidado
de personas a su cargo o suministros;
Si, desde su último reporte, algún miembro del grupo ha
estado evitando o huyendo de la ley para evitar
enjuiciamiento, custodia o encarcelamiento después de
una condena por un delito mayor (felony) o está violando
su libertad condicional (probation o parole).
Si, desde su último reporte, algún miembro del grupo ha
sido condenado por haber cometido un delito mayor
(felony) relacionado a las drogas después del 22 de agosto
de 1996; es decir, por manufacturar, vender, o distribuir
alguna substancia controlada, o por cualquier actividad en
conexión con estos actos ilegales; por cosechar, cultivar, o
preparar mariguana, o por involucrar a un menor en las
actividades mencionadas.
REPORTES OBLIGATORIOS DE CAMBIOS DURANTE
EL PERÍODO DE CERTIFICACIÓN
Tiene que reportar los siguientes cambios antes de que pasen
diez (10) días contados a partir de la fecha en que el cambio
ocurrió, aun si no es su mes del reporte. Tiene que reportar:
• Cuando los ingresos de su grupo son más que el 130% del
nivel federal de pobreza para el tamaño de su grupo (límite
de ingresos permitidos para recibir beneficios de CalFresh
- CalFresh IRT).
• Si usted está trabajando, cumpliendo con la regla de
trabajo para adultos con la capacidad de trabajar y sin
personas bajo su cuidado (ABAWD), y sus horas de trabajo
o se reducen a menos de 20 horas por semana u 80 horas
por mes. Las reglas de CalFresh limitan el recibir
beneficios de CalFresh a un máximo de 3 meses durante
un período de tres años para los ABAWD que no estén
trabajando ni participando en otras actividades permitidas.
Usted está exento de las reglas de trabajo para los ABAWD
y no necesita reportar una reducción en sus horas de
trabajo si:
• Está viviendo en un condado que da una exención
para la regla de trabajo para los ABAWD debido al
alto nivel de desempleo;
• Tiene menos de 18 años o más de 50 años de edad;
• Tiene una certificación médica que indica que está
imposibilitado física o mentalmente para trabajar;
• Cumple con las reglas de Welfare-to-Work de CalWORKs;
• Está cuidando a una persona lesionada o enferma que
necesitará ayuda por más de 30 días;
• Está participando en un programa de tratamiento
contra el alcohol o las drogas que le impide trabajar 30
horas o más a la semana;
• Está recibiendo o ha solicitado beneficios del Seguro
contra Desempleo.
REPORTES VOLUNTARIOS DE CAMBIOS
Usted también puede reportar voluntariamente otra información aun
cuando no es su mes del repor te. El repor tar información
voluntariamente puede causar que se aumenten o que se reduzcan
los beneficios de su grupo. Vea algunos ejemplos a continuación.
El Condado tomará acción antes de que pasen diez (10) días a
partir de cuando usted proporcione verificación. Una excepción es
cuando el aumento resulta porque se añade a otra persona a su
caso. En tal situación, el Condado tomará acción para aumentar
sus beneficios el primer día del mes después de cuando
proporcione verificación. Aun cuando ya haya reportado algo al
Condado, tendrá que reportarlo también en su próximo SAR 7
o recertificación.
Algunos ejemplos de reportes voluntarios que pudieran causar que
sus beneficios aumenten incluyen:
• Pérdida de ingresos;
• Un miembro del grupo se convier te en una persona
incapacitada/discapacitada o cumple 60 años de edad;
• Un miembro del grupo empieza a pagar mantenimiento de
hijos por orden de la corte;
• Hay un nuevo miembro del grupo en el hogar;
• Aumento en el costo de albergue/vivienda;
• Gastos médicos.
(Continúa en la siguiente página)
CF 23 SAR (SP) (6/13) REQUIRED FORM - SUBSTITUTES PERMITTED
11/19/2013
11:22 AM
Page 1 of p.
2 79
County of Orange
Bid 017-976001-GH
REPORTES VOLUNTARIOS DE CAMBIOS - Continuación
BENEFICIOS TRANSICIONALES DE CALFRESH
Algunos ejemplos de reportes voluntarios que pudieran causar
que sus beneficios se reduzcan incluyen:
• Un incremento o aumento en los ingresos que es menos
que el límite de ingresos permitidos para recibir beneficios
de CalFresh (CalFresh IRT);
• Alguien sin ingresos se muda fuera del hogar de usted;
• Muere alguien sin ingresos que vivía en el hogar de usted;
• Alguien que tiene ingresos se muda al hogar de usted;
• Una reducción en el costo de vivienda.
El Programa de California de Beneficios Transicionales de
CalFresh proporciona beneficios durante cinco meses para los
grupos que dejan de recibir beneficios de CalWORKs
(Programa de California de Opor tunidades de Trabajo y
Responsabilidad hacia los Niños).
PUEDE reportar cambios en cualquier momento durante el
período de certificación por medio del:
• Correo o teléfono, o en persona en la oficina del Condado
encargada del Programa de CalFresh, o entregando un
“Reporte sobre la situación a mediados del período”
(formulario SAR 3).
Si su grupo comienza a recibir beneficios transicionales de
CalFresh, no tiene que reportar mientras que esté recibiendo
estos beneficios.
Si está recibiendo beneficios transicionales de CalFresh, puede
volver a presentar su solicitud para ver si puede recibir más
beneficios. Si se aprueba dicha solicitud para recibir beneficios
regulares de CalFresh, se aplicarán todas las reglas normales
sobre el requisito de reportar.
OTROS CAMBIOS
Hay otras circunstancias que requerirán que el Condado
reduzca o descontinúe sus beneficios durante el período de
certificación en que ocurran. A continuación aparecen algunos
ejemplos:
• Algún miembro del grupo recibe una sanción;
• Alguien en su grupo recibe beneficios como miembro de
otro grupo;
• La situación de alguien en el grupo cambia en relación al
Programa de California para la Asistencia Alimentaria
(California Food Assistance Program).
CF 23 SAR (SP) (6/13) REQUIRED FORM - SUBSTITUTES PERMITTED
11/19/2013 11:22 AM
Page 2 of 2
p. 80
County of Orange
Bid 017-976001-GH
INFORMACIÓN IMPORTANTE - FAVOR DE LEER
Nuevos requisitos para reportar
para asistencia monetaria y beneficios de CalFresh
El Condado está cambiando de un sistema de
reportar cada trimestre (Quarterly Reporting - QR)
a un nuevo sistema de reportar dos veces al año
(Semi-Annual Reporting - SAR). A continuación
se explican los cambios que van a empezar dentro
de poco. Le avisaremos cuando empiecen estas
nuevas reglas.
El formulario de reporte
Anteriormente, usted entregó un formulario QR 7
cada 3 meses. Dentro de poco, sólo tendrá que
entregar un reporte cada seis meses.
El reporte que se tiene que hacer cada seis
meses se llama el formulario SAR 7. El otro
reporte
será
el
formulario
anual
de
redeterminación/recertificación (RD/RC).
El SAR 7 se tiene que entregar seis meses
después de su reporte anual de RD/RC. Siempre
se tiene que entregar para el día 5 del mes. Si no
entrega su SAR 7 completo a más tardar al final
del primer día hábil del próximo (séptimo) mes, su
asistencia se descontinuará.
Ejemplo: Usted completó su reporte anual
RD/RC en febrero. Se tendrá que entregar su
SAR 7 seis meses después - para el 5 de agosto.
Tiene que entregarle a su trabajador su SAR 7
completo a más tardar al final del primer día hábil
de septiembre o se descontinuarán sus
beneficios. Perderá asistencia a menos que tenga
un motivo justificado para haber entregado el
reporte después de la fecha límite.
Así como con el formulario QR 7, usted tiene que
contestar todas las preguntas en el SAR 7,
adjuntar pruebas, firmar y poner la fecha en el
formulario, y devolverlo a más tardar en la fecha
anotada en el reporte.
Cambios en las reglas sobre el límite de ingresos
permitidos (IRT por sus siglas en inglés)
El IRT es la cantidad del total de los ingresos
mensuales que tiene que reportar antes de que
pasen 10 días. “Total de los ingresos mensuales”
significa cualquier cantidad de dinero que reciba.
Cada vez que su IRT cambie, el Condado le
avisará por escrito.
Para asistencia monetaria: La cantidad de
ingresos que tiene que reportar antes de que
pasen 10 días está cambiando. El IRT se basa
en el total de sus ingresos y el número de
personas en su hogar.
Anteriormente,
descontinuamos sus beneficios si el total de sus
ingresos excedió su IRT. Bajo las nuevas reglas,
si reporta ingresos que exceden su IRT, es
posible que el Condado reduzca o descontinúe
sus beneficios.
Ejemplo: Si su IRT es $900 y recibe ingresos de
$800, no tiene que reportar el cambio hasta la
fecha en que tiene que entregar su próximo
reporte. Si recibe ingresos de $901 o más, tiene
que reportarlo a su trabajador antes de que
pasen 10 días. Se reducirán sus beneficios y su
trabajador le dará un nuevo IRT.
Para los beneficios de CalFresh: Anteriormente,
usted no tenía un IRT. Dentro de poco usted sí
tendrá un IRT basado en el tamaño de su hogar. Si
reporta ingresos que exceden su IRT, es posible
que el Condado descontinúe sus beneficios.
No cambian las otras reglas - obligatorias ni
voluntarias - en relación al requisito de reportar.
Es posible que los reportes voluntarios aumenten
su asistencia.
TEMP SAR 1 (SP) (10/12) NEW REPORTING REQUIREMENTS FOR CASH AID AND CALFRESH
11/19/2013 11:22 AM
p. 81
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 82
Construya un mejor
futuro para su familia
11/19/2013 11:22 AM
•
•
•
Tener comunicación con su pareja en lo
relacionado a asuntos de la
salud reproductiva.
Planear el número de niños que quiere
tener, al igual que cuánto tiempo va
ha haber entre cada uno de ellos, para
que pueda satisfacer las necesidades
económicas y emocionales de su familia.
Mejorar su habilidad para ser
autosuficiente previniendo un embarazo
no planeado.
Obtenga los beneficios de los servicios
de planificación familiar, los cuales le
pueden ayudar a:
•
Hablar con sus niños acerca del sexo
seguro y la prevención del embarazo.
County Stamp Box
California Family Planning Information
and Referral Service
(Servicio de información y referencia
para la planificación familiar
en California)
1-800-942-1054
State of California
(Estado de California)
(Secretaría de Salud y Servicios Humanos)
(Departamento de Servicios Sociales)
Planificación familiar...
Comprometiéndose para
un futuro saludable
County of Orange
Hágalo por usted.
Hágalo por las personas que ama.
PUB 275 (SP) (04/07)
p. 83
Bid 017-976001-GH
11/19/2013 11:22 AM
•
•
•
•
•
•
•
•
Contestar preguntas acerca de todas las
preocupaciones que tenga sobre la
salud reproductiva.
Aprender cómo autoexaminarse para el
cáncer del seno.
Recibir pruebas para detectar el cáncer en el
sistema de reproducción.
Aprender acerca de cómo prevenir y evitar
propagar enfermedades transmitidas
sexualmente, incluyendo el virus de la
inmunodeficiencia humana (HIV por sus siglas
en inglés) y el Síndrome de Inmunodeficiencia
Adquirida (AIDS por sus siglas en inglés).
Obtener pruebas y tratamiento para
enfermedades transmitidas sexualmente.
Aprender acerca de anticonceptivos de
emergencia y si esto sería una opción
correcta para usted si algún día lo llegara
a necesitar.
Obtener anticonceptivos para ayudarle a
prevenir un embarazo no planeado.
Encontrar el método que mejor se ajuste a su
estilo de vivir. Hay una amplia variedad de
opciones — desde la píldora hasta el anillo o
inyecciones y más.
Su proveedor local de servicios de
planificación familiar puede ayudarle a:
Son confidenciales, lo cual significa
que es algo privado entre usted y
su médico.
Están disponibles para los hombres y las
mujeres, incluyendo a los adolescentes.
No son caros — las personas que
reciben beneficios del Programa de
California de Oportunidades de Trabajo
y Responsabilidad hacia los Niños
(CalWORKs) pueden recibir estos
servicios gratuitamente o a bajo costo.
•
•
•
Estos servicios:
Bid 017-976001-GH
Haga el compromiso hoy.
1-800-942-1054
Llame a “California Family Planning
Information and Referral Service” (servicio
de información y referencia para la
planificación familiar) para que le den el
nombre, dirección y número de teléfono de
un proveedor de servicios de planificación
familiar en su área. El teléfono es:
Vea la sección amarilla de su directorio
telefónico bajo “Family Planning
Information” (información sobre
planificación familiar).
•
•
Vaya a su doctor, o al departamento de
salud del condado o a su plan de cuidado
de la salud.
•
En su comunidad, usted puede recibir
los servicios de planificación familiar:
Planificación familiar — Para el futuro de su familia
County of Orange
p. 84
■
■
■
■
Su silla de ruedas no cabe en los baños o en las salas
donde se llevan a cabo los exámenes o las entrevistas.
Los hombres reciben entrenamiento para empleos
que pagan más y las mujeres reciben entrenamiento
para empleos que pagan menos.
El Condado no quiere proporcionarle entrenamiento
porque dicen que usted es “demasiado viejo”.
No le permiten adoptar a un bebé porque la raza
de usted es diferente a la del bebé.
QUEJAS DE DISCRIMINACIÓN
Si usted cree que ha sido víctima de discriminación, puede
presentar una queja al Condado, al Estado, y al Gobierno
Federal - una queja separada para cada uno. La oficina
específica del Gobierno Federal a la cual debe comunicarse
depende de qué programa se trata su queja.
Puede presentar una queja de discriminación a:
1. PARA TODOS LOS PROGRAMAS QUE SE
ADMINISTRAN POR EL DEPARTAMENTO DE
BIENESTAR PÚBLICO DEL CONDADO:
El coordinador de derechos civiles del Condado.
Pídale a la oficina del Condado el nombre,
dirección, y número de teléfono de su
coordinador de derechos civiles. Él/Ella
investigará su queja independientemente.
2. Civil Rights Bureau
744 P Street, MS 8-16-70
(916) 654-2107
(866) 741-6241 (Gratuito)
3. PARA EL PROGRAMA DE CALFRESH:
Director, Office of Civil Rights,
(202) 720-6382 (voz y TTY)
4. PARA TODOS LOS OTROS PROGRAMAS:
Office of Civil Rights
90 7th Street, Suite 4-100
(415) 437-8310 (voz)
(415) 437-8311 (TDD)
LÍMITES DE TIEMPO PARA TOMAR ACCIÓN
■
■
■
■
■
■
■
■
■
Si usted es víctima de discriminación, tiene que
presentar su queja antes de que pasen 180 días a partir
de cuando ocurrió la discriminación. Si la
discriminación también afectó la cantidad de sus
beneficios o servicios, también tiene que pedir una
audiencia con el Estado antes de que pasen 90 días.
Una investigación de discriminación no puede cambiar
la cantidad de sus beneficios o servicios... solamente
una audiencia con el Estado puede hacer eso.
LÍMITES EN CUANTO A CIERTOS DERECHOS
CalFresh (estampillas para comida)
Cuidado de Crianza Temporal (FC)
Programa de Servicios de Apoyo en el Hogar (IHSS)
Programa de Pagos de Asistencia para Parientes que
Son los Tutores Legales de un Menor (Kin-GAP)
Salud Mental
Programa de Servicios Múltiples para Personas
Mayores (MSSP)
Programa de Servicios de Cuidado Personal (PCSP)
Asistencia Monetaria para Refugiados (RCA)
Servicios Sociales
STATE OF CALIFORNIA
(ESTADO DE CALIFORNIA)
SUS
DERECHOS
BAJO LOS PROGRAMAS DE
ASISTENCIA PÚBLICA DE
CALIFORNIA
…… para las personas que
solicitan o reciben asistencia
pública en California
Díganos si necesita ayuda
debido a una incapacidad/
discapacidad.
County of Orange
Este folleto está disponible en los siguientes
idiomas en la oficina de bienestar público de su
condado y en el sitio web: www.cdss.ca.gov
• Japonés • Ruso
• Árabe
• Coreano • Español
• Armenio
• Camboyano • Laosiano • Español (letra grande)
• Mien
• Tagalo
• Chino
• Portugués • Ucraniano
• Farsí
• Penjabi • Vietnamita
• Hmong
También está disponible en Braille, así como una
versión fácil de leer (letra grande), o grabada (audio CD).
DEPARTMENT OF SOCIAL SERVICES
(DEPARTAMENTO DE SERVICIOS SOCIALES)
HEALTH AND HUMAN SERVICES AGENCY
(SECRETARÍA DE SALUD Y SERVICIOS HUMANOS)
Aunque usted tenga derecho a la privacidad y la
confidencialidad, hay ciertas leyes que permiten
excepciones limitadas. Usted puede pedirle al
Condado información sobre estas leyes.
PREGUNTAS
Si tiene alguna pregunta sobre los derechos enumerados en
este folleto, llame a la Oficina de Preguntas y Respuestas al
Público: (800) 952-5253 (Gratuito). El número gratuito de
TDD (aparato de telecomunicaciones para las personas
sordas) es (800) 952-8349.
■
Programa de Asistencia para Adopciones (AAP)
Servicios para la Protección de Adultos (APS)
Programas de Alcohol y Drogas (ADP)
Programa de California para la Asistencia
Alimentaria (CFAP)
Programa de Asistencia Médica de California (Medi-Cal)
Programa de California de Oportunidades de Trabajo
y Responsabilidad hacia los Niños (CalWORKs)
Cuidado de Niños del Programa de CalWORKs
Programa para la Transición de la Asistencia
Pública al Trabajo (WTW) bajo el Programa de
CalWORKs
Programa de Asistencia Monetaria para
Inmigrantes (CAPI)
Servicios para el Bienestar de los Niños (CWS)
Programa de Asistencia Dental de California
(Denti-Cal)
Programa de Evaluación Temprana y Periódica,
Diagnosis, y Tratamiento (EPSDT)
PROGRAMAS CUBIERTOS EN ESTE FOLLETO
■
■
■
■
■
■
■
■
■
■
■
PUB 13 (SP) (6/11)
11/19/2013 11:22 AM
p. 85
Bid 017-976001-GH
1. Entender lo que está pasando con su solicitud y
su asistencia.
2. Obtener explicaciones, por escrito y orales, sobre
su solicitud y sus beneficios.
USTED TIENE DERECHO A …
Todas las personas y organizaciones que proporcionan
asistencia pública tienen que respetar los derechos que
usted tiene. Le pueden ayudar a entender y solicitar
beneficios y servicios.
SUS DERECHOS
11/19/2013 11:22 AM
4. Presente una queja. Hay 4 maneras de hacer esto:
■ Queja informal: Puede pedir hablar con un supervisor
sobre problemas que tiene con un trabajador o para
revisar las reglas y la acción que el Condado propone
tomar en relación a sus servicios o asistencia.
■ Audiencia con el Estado: Pida una audiencia con el
Estado si hay un problema con su asistencia o
sus servicios. Tiene que pedir una audiencia
antes de que pasen 90 días a partir de la
acción del Condado. Es posible que pueda
pedir una audiencia después de los 90 días si tiene
un motivo justificado como una enfermedad o
una incapacidad/discapacidad.
■ Queja de discriminación: Si cree que el Condado ha
discriminado contra usted, puede presentar una
queja de discriminación - al coordinador de
derechos civiles del Condado o a la Oficina de
Derechos Civiles del Estado, y al Gobierno Federal.
Tiene que hacer esto antes de que pasen 180 días a
partir de la discriminación. Para más información
sobre esto, vea la sección que comienza con
“Prohibida la discriminación”. Si la discriminación
también afecta sus beneficios o servicios, también
tiene que pedir una audiencia con el Estado
1. Mantenga un expediente de toda su información,
todos sus documentos, y cualquier contacto con
el Condado que haya tenido.
2. Obtenga un recibo para cada documento que entrega.
SI TIENE PROBLEMAS CON SU ASISTENCIA O
SUS SERVICIOS:
3. Obtener un recibo para cada documento que entrega.
4. Ver el expediente de su caso.
5. Ver las leyes y los ordenamientos del Estado y del
Condado.
6. Pedirle a un juez que revise cualquier decisión del
Condado sobre su elegibilidad, beneficios, o servicios.
7. No ser víctima de discriminación en cuanto a
recibir beneficios o servicios de los programas.
8. Presentar una queja sobre cualquier discriminación.
9. Obtener ayuda adicional del personal del Condado
para asegurarse de que reciba sus beneficos si tiene
una incapacidad/discapacidad o un impedimento
que le hace dificil entender las reglas del programa.
10. Mantener su información de una manera confidencial.
11. Ser tratado con cortesía y respeto.
Puede pedir una audiencia con el Estado si no
está de acuerdo con una acción del Condado en
relación a sus beneficios o servicios.
También puede pedir una audiencia con el
Estado si el Condado no le da los beneficios o
servicios que usted cree que debe recibir.
Un juez de leyes administrativas del Estado está a
cargo de la audiencia con el Estado. Un representante
del Condado estará presente también en la audiencia
para explicar por qué tomó su acción el Condado.
Una audiencia con el Estado no es una audiencia
de la corte. Usted tiene el derecho de llevar un
representante a la audiencia. Hay servicios legales
gratuitos en cada condado los cuales se indican
en la segunda página de las notificaciones del
Condado. Puede llevar testigos. Tiene el derecho
de tener un intérprete gratis. Pregúntele al Condado
cómo hacerlo.
• Si tiene un problema con el Programa de
Asistencia General/Ayuda General, tiene que
pedir una audiencia con el Condado.
• Si tiene un problema con sus beneficios de
Seguro Social, tiene que comunicarse con la
Administración del Seguro Social.
El Condado tiene que darle una notificación por lo
menos 10 días antes de que entre en vigor cualquier
acción que cambie su asistencia o sus servicios. Si pide
una audiencia antes de que entre en vigor la acción,
puede continuar recibiendo asistencia hasta que se
lleve a cabo la audiencia (“aid paid pending”). Esto
significa que su asistencia quedará igual hasta que se
emita una decisión sobre la audiencia.
USTED TIENE QUE pedir una audiencia cada
vez que reciba una notificación sobre cualquier
acción con la cual usted no está de acuerdo.
CONTINUACIÓN DE SU ASISTENCIA O SUS
SERVICIOS MIENTRAS QUE ESPERA UNA
AUDIENCIA CON EL ESTADO
■
■
■
■
AUDIENCIA CON EL ESTADO
■
si desea disputar la decisión del Condado en
relación a sus beneficios o servicios.
Procedimiento para presentar quejas: Puede presentar
una queja al Condado si tienen un procedimiento
para presentar quejas. Esto no protege sus
beneficios de la misma manera que lo hace el
pedir una audiencia con el Estado.
El Condado no le ayuda a obtener cintas de grabación
(audio tapes) de la orientación para un programa para
ayudarle con una incapacidad/discapacidad que le hace
difícil leer.
Un trabajador le trata de una manera diferente al
darse cuenta de su religión o su afiliación política.
No puede llegar a sus citas porque el edificio del
Condado no tiene un ascensor.
■
■
■
Un trabajador les habla a personas de cierto
grupo étnico sobre más programas y servicios
que a personas en otros grupos étnicos.
Bid 017-976001-GH
■
■
EJEMPLOS DE DISCRIMINACIÓN
Bajo las leyes del Estado, las oficinas que proporcionan
asistencia pública no pueden proporcionarle beneficios
o servicios que son diferentes a la asistencia que
proporcionan a otras personas basándose en su:
Raza, Color, Origen Nacional (incluyendo su idioma),
Grupo Étnico, Edad, Incapacidad/Discapacidad,
Religión, Sexo, Orientación Sexual, Afiliación Política,
Estado Civil, o Relación Doméstica
Las leyes federales también prohíben la discriminación basada
en algunas, aunque no todas, las razones antes mencionadas.
Las leyes federales también prohíben:
1. El demorar o negar la colocación de un niño para
su adopción o su ingreso en un hogar de cuidado
de crianza temporal basándose en la raza, color, u
origen nacional de los padres adoptivos/de crianza
temporal o del niño;
2. El negarle a cualquier persona la oportunidad de
hacerse padre/madre adoptivo o de crianza
temporal basándose en la raza, color, u origen
nacional de la persona o del niño involucrado.
PROHIBIDA LA DISCRIMINACIÓN
1. Por teléfono: Pida una audiencia con el Estado,
comunicándose con el Departamento de Servicios
Sociales de California (CDSS) al (800) 743-8525 ó
(800) 952-5253.
2. Complete la segunda página de su notificación de
acción (NOA) o envíe una petición por escrito al
CDSS a la siguiente dirección:
744 P Street M.S. 09-17-37
CÓMO PEDIR UNA AUDIENCIA CON EL ESTADO
County of Orange
p. 86
County of Orange
Bid 017-976001-GH
Báo Cáo Chương Trình Trợ Cấp Thực
Phẩm Hàng Năm Qua Điện Thoại
Đơn Báo Cao Chương Trình Thực Phẩm Hàng Năm
Các mẫu đơn phãi hoàn tất, ký tên và gởi lại văn phòng trước khi
phỏng vấn quí vị qua điện thoại
Bản Thông Cáo Điện Thoại Báo Cáo Hàng Năm
CalFresh Application for CalFresh Benefits
No Form #
CF 285 (09/13)
Bạn Có Muốn Đăng Ký Đi Bầu Không?
NVRA Voter Preference
Form (VN) (01/13)
Mẫu Đăng Ký Cử Tri California
No Form #
Thông cáo/tài liệu để quí vị sử dụng – quí vị không cần gởi lại văn phòng.
Do You Know? Your Family May Qualify for Medi-Cal
F063-19-949 (10/13)
Notice of Language Services
GEN 1365 (03/08)
CalFresh Benefits How to Report Household Changes
(SAR)
CalFresh Benefits How to Report Household Changes
(CR)
Các Yêu Cầu Báo Cáo Mới Đối Với Trợ Cấp Tiền Mặt
và CalFresh
CF 23 SAR (06/13)
CF 23 CR (09/13)
TEMP SAR 1 VN (10/12)
Kế Hoạch Hóa Gia Đình.... Cam Kết Cho Một Tương Lai
Lành Mạnh
Pub 275 VN (04/07)
Quyền Lợi Của Quí Vị
PUB 13 VN (06/11)
NACF Phone-In RRR Cover Letter - Vietnamese -1/1/14
11/19/2013 11:22 AM
p. 87
County of Orange
Bid 017-976001-GH
THѬ +ҼN BÁO CÁO CHѬѪNG TRÌNH THӴC PHҬM HÀNG NĂM
4XtYӏÿã ÿѭӧc thông báo rҵng thӡi gian WKөhѭӣng chѭѫng trình Thӵc Phҭm cӫa quí
Yӏÿѭӧc kӃt thúc vào cuӕi tháng tӟi và TXtYӏsӁ nhұn ÿѭӧc mӝt cuӝc hҽn ÿӇ tiӃp tөc
chѭѫng trình này.
4XtYӏ ÿã ÿѭӧc lên lӏch trình cho cuӝc phӓng vҩn qua ÿiӋn thoҥi. Nhân viên sӁ gӑi ÿiӋn
thoҥi cho TXtYӏtheo sӕ ÿiӋn thoҥi trѭӟc ÿó mà TXtYӏÿã cung cҩp.
Xin vui lòng gӑi cho nhân viên càng sӟm càng tӕt nӃu:
x
Ngày phӓng vҩn hoһc thӡi gian không thuұn tiӋn cho TXtYӏvà TXtYӏmuӕn sҳp
xӃp lҥi.
x
4XtYӏ muӕn nhân viên gӑi cho TXtYӏӣ mӝt sӕ khác (nhѭ sӕ ÿiӋn thoҥi di ÿӝng
hoһc ÿiӋn thoҥi nѫi làm viӋc).
x
4XӏYӏ thích ÿѭӧc phӓng vҩn trӵc tiӃp và muӕn yêu cҫu mӝt cuӝc hҽn Wҥi văn
phòng.
Vui lòng hoàn tҩt, ký tên YjÿӅQJjy các mүu ÿѫn ÿính kèm (Ĉѫn Xin Thӵc
Phҭm/DFA 285-A1, Ĉѫn Chӭng Nhұn vӅLӡi Khai/DFA 285-A2, và QuyӅn Lӧi và
Trách NhiӋm Fӫa 4Xt9ӏ/DFA 285-A3). Gӣi lҥi tҩt Fҧcho chúng tôi trong phong bì
bѭu phí trҧ trѭӟc ÿѭӧc cung cҩp ngay lұp tӭc. Nhӳng thông tin ÿính kèm khác
WKuTXtYӏgiӳOҥi sӳGөng/lѭu trӳ. Chúng tôi cҫn SKҧi có các mүu ÿѫn hoàn tҩt
này trѭӟc khi chúng tôi hoàn thành/thӵc hiӋn cuӝc SKӓng vҩn qua ÿiӋn WKRҥi.
NӃu chúng tôi cҫn nhӳng giҩy tӡNKic liên quan ÿӃn TXtYӏ, chúng tôi VӁQyi cho
TXtYӏbiӃt sau khi chúng tôi kiӇm chӭng các mүu ÿѫn hoһc trong thӡi gian SKӓng
vҩn qua ÿiӋn WKRҥi.
XIN LѬU Ý
x
Không hoàn tҩt cuӝc phӓng vҩn thì chѭѫng trình Thӵc Phҭm sӁ Eӏngѭng.
x
NӃu TXtYӏkhông thӇgiӳKҽn, TXtYӏFyWUich nhiӋm ÿӇxin Oҥi cuӝc Kҽn khác.
x
Báo Cáo Tam Cá NguyӋt (QR7) không cҫn thiӃt SKҧi hoàn tҩt trong thӡi gian báo cáo
chѭѫng trình Thӵc Phҭm hàng năm. Tuy nhiên, lѭѫng bәng hoһc lӧi tӭc Fӫa Fҧgia ÿình
vҭn SKҧi cung cҩp khi TXtYӏgӣi vào cùng vӟi nhӳng mүu ÿѫn ÿính kèm.
x
Nhӳng giҩy tӡPjFK~ng tôi cҫn thì SKҧi ÿѭӧc gӣi Oҥi trong vòng 10 ngày kӇtӯQJjy ÿѭӧc
yêu cҫu.
11/19/2013 11:22 AM
p. 88
County of Orange
Bid 017-976001-GH
APPLICATION FOR CALFRESH BENEFITS
If you have a disability or need help with this application, let the County Welfare Department (County) know and
someone will help you.
If you prefer to speak, read, or write in a language other than English, the County will get someone to help you
at no cost to you.
How do I apply?
Use this application if you are applying for CalFresh benefits only. CalFresh is a food assistance program to help
you with the cost of buying food for your household. If you wish to apply for programs other than CalFresh such
as, CalWORKs or Medi-Cal, please ask for an application to apply for other programs. You can also apply for
CalFresh or other programs online by going to http://www.benefitscal.org/. You can see if you may be eligible by
going to http://www.cdss.ca.gov/foodstamps/PG849.htm.
• Fill out the whole application form, if you can. You must at least give the County your name, address, and
signature (question 1 on page 1) to begin the application process.
• Give the application to the County in person, by mail, by fax, or online.
• The day the County receives your signed application starts the time to give you an answer on whether you can
get benefits. If you are in an institution, this time starts from the day you leave.
What do I do next?
• Read about your rights and your responsibilities (Program Rules pages 1 through 3) before you sign the
application.
• You must have an interview with the County to discuss your application. Most interviews are done by phone,
but it can be done in person at the County office or other place arranged with the County. If you have a disability,
other arrangements can be made.
• If you did not fill out all of the application, you can finish it during your interview.
• You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.
How long will it take?
It may take up to 30 days to process your application. You may be able to get benefits within 3 calendar days, if:
• Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand
or in checking or savings accounts is $100 or less; or
• Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and
cash on hand or in checking or savings accounts; or
• You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your
income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.
To help the County see if you can get benefits in three days, please answer questions 1, 6 through 8, 11, and 16,
and give the County proof of your identify (if you have it) with the application.
The County will send you a letter to let you know if your household is approved or denied CalFresh benefits.
CF 285 (9/13)
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County of Orange
Bid 017-976001-GH
What do I need for my interview?
To avoid delays, bring proof of the following with you to your interview. Keep your interview even if you do not
have the proof. The County may be able to help if you need help getting proof. During the interview, the County
will go over the information on the application and will ask you questions to see if you can get CalFresh benefits
and the amount of benefits you can get.
Proof Needed to Get Benefits
• Identification (Driver’s License, State ID card,
passport).
• Where you live (a rental agreement, current bill
with your address listed).
• Social Security Numbers (see note below about
certain noncitizens).
• Money in the bank for all the people in your
household (recent bank statements).
• Earned income of everyone in your household for
the past 30 days (recent pay stubs, a work
statement from an employer). NOTE: If selfemployed, income and expense or tax records.
• Unearned income (Unemployment benefits, SSI,
Social Security, Veteran’s benefits, child support,
worker’s compensation, school grants or loans,
rental income, etc.).
• Lawful immigration status ONLY for noncitizens
applying for benefits (an Alien Registration Card,
visa)
NOTE: Certain noncitizens applying for
immigration status based on domestic violence,
crime prosecution or trafficking may not need this
proof. They also may not need a Social Security
Number.
Proof Needed to Get More CalFresh Benefits
• Housing costs (rent receipts, mortgage bills,
property tax bill, insurance documents).
• Phone and utility costs.
• Medical expenses for anyone in your household
who is elderly (60 and older) or disabled.
• Child and adult care costs due to someone
working, looking for work, attending training or
school, or participating in a required work activity.
• Child support paid by a person in your
household.
How do I get/use my CalFresh benefits?
• The County will mail or give you a plastic Electronic Benefit Transfer (EBT) card. Benefits will be put on the
card when your application is approved. Sign your card when you get it. You will set up a Personal Identification
Number (PIN) to use your card.
• If your EBT card is lost, stolen, or destroyed, or you think someone may know your PIN number that you don’t
want to use your benefits call (877) 328-9677 or call the County right away. Make sure all responsible adults
and your authorized representative also know how to report one of these problems right away. If you do not
report that another person you do not want to spend your benefits has your PIN and you do not get your PIN
• You can use your CalFresh benefits to buy almost all foods, as well as seeds and plants to grow your own food.
You cannot buy alcohol, tobacco, pet food, some types of cooked food, or anything that is not food (like
toothpaste, soap, or paper towels).
• CalFresh benefits are accepted at most grocery stores and other places that sell food. For a list of locations
near you that accept EBT please go to: https://www.ebt.ca.gov or https://www.snapfresh.org.
• CalFresh benefits are only for you and your household members. Keep your benefits safe. Do not give out
your PIN number. Do not keep your PIN number with your EBT card.
What if I am homeless?
Please let the County know right away if you are homeless so they can help you figure out an address to use to
accept your application and get notices from the County regarding your case. For CalFresh, homeless means
you are:
A. Staying in a supervised shelter, halfway house, or similar place.
B. Staying at the home of another person or family for no more than 90 days straight.
C. Sleeping in a place not designed for, or normally used as, a place to sleep (e.g., a hallway, a bus station,
a lobby, or similar places).
CF 285 (9/13)
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County of Orange
Bid 017-976001-GH
RIGHTS AND RESPONSIBILITIES
You have a responsibility to:
•
•
•
•
•
•
Give the County all information needed to determine your eligibility.
Give the County proof of the information you have when it is needed.
Report changes as required. The County will give you information about what, when, and how to report. If
you don’t meet your household’s reporting requirements your case will be closed or your CalFresh benefits
may be lowered or stopped.
Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your
case.
Fully cooperate with County, State, or federal personnel if your case is selected for review or investigation to
ensure that your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will
result in loss of your benefits.
Pay back any CalFresh benefits that you were not eligible to get.
You have the right to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Turn in an application for CalFresh giving only your name, address, and signature.
Have an interpreter provided by the State at no cost if you need one.
Have information given to the County kept confidential, unless directly related to the administration of County
programs.
Withdraw your application at any time prior to the County determining eligibility.
Ask for help to fill out your application for CalFresh and get an explanation of the rules.
Ask for help to get proof that is needed.
Be treated with courtesy, consideration, and respect, and not be discriminated against.
Get CalFresh benefits within 3 days if you qualify for Expedited Service.
Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility
determined within 30 days.
Get at least 10 days to give the County proof that is needed to make a determination of eligibility.
Get written notice at least 10 days before the County lowers or stops your CalFresh benefits.
Discuss your case with the County and to review your case when you ask to do so.
Ask for a State hearing within 90 days if you do not agree with the County about your CalFresh case. If you
ask for a hearing before an action on your CalFresh case takes place, your CalFresh benefits will stay the
same until the hearing or the end of your certification period, whichever is earlier. You can ask the County to
let your benefits change until after the hearing to avoid having to pay back any over paid benefits. If the
Administrative Law Judge rules in your favor, the County will give back to you any benefits that were cut.
Ask about your hearing rights or for a legal aid referral at the toll-free phone number – 1-800-952-5253 or for
hearing or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal
aid or welfare rights office.
Bring a friend or someone with you to the hearing if you do not want to go alone.
Get assistance from the County to register to vote.
Report changes that you are not required to report, if it may increase your CalFresh benefits.
Give proof of your household’s expenses that may help you get more CalFresh benefits. Not giving proof to
the County is the same as saying that you do not have that expense and you will not be able to get more
CalFresh benefits.
Let the County know if you would like someone else to use your CalFresh benefits for your household or help
with your CalFresh case (Authorized Representative).
CF 285 (9/13)
11/19/2013 11:22 AM
p. 91
County of Orange
Bid 017-976001-GH
Program Rules and Penalties
You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get
CalFresh benefits that you are not eligible to receive, or to help someone else get benefits that they are not eligible to receive.
You must pay back any benefits you get that you were not eligible to receive.
I understand that if I...
Commit an intentional program violation by doing
any of the following:
I may...
•
hide information or make false statements
•
•
use electronic benefit transfer (EBT) cards that belong
to someone else or let someone else use my card
use CalFresh benefits to buy alcohol or tobacco
•
trade, sell, or give away CalFresh benefits or EBT
cards
•
•
trade CalFresh benefits for controlled substances,
such as drugs
•
•
•
give false information about who I am and where I live
so I can get extra CalFresh benefits
have been convicted of trading or selling CalFresh
benefits worth more than $500, or trading CalFresh
benefits for firearms, ammunition, or explosives
•
to me
lose CalFresh benefits for 24 months for the second
offense and be required to repay all CalFresh benefits
overpaid to me
lose CalFresh benefits permanently for the third offense
to me
be fined up to $250,000, imprisoned up to 20 years, or
both
lose CalFresh benefits permanently for the second
offense.
lose CalFresh benefits for 10 years for each offense
•
lose CalFresh benefits permanently
•
•
•
•
Important Information for Noncitizens
•
•
•
You can apply for and get CalFresh benefits for people who are eligible, even if your family includes others who are not
eligible. For example, immigrant parents may apply for CalFresh benefits for their U.S. citizen or qualified immigrant
children, even though the parents may not be eligible.
Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and
confidential.
The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S. Citizenship
and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except
cases of fraud.
Opting Out
You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s)
who are not applying for CalFresh benefits. The County will need to know their income and resource information to correctly
determine your household’s benefits. The County will not contact USCIS about the people who don’t apply for CalFresh
benefits.
Use of Social Security Numbers (SSN)
Everyone applying for CalFresh benefits needs to provide a SSN, if they have one, or proof that they have applied for a SSN
(such as a letter from the Social Security Office). The County may deny CalFresh benefits for you or any member of your
household who does not give us a SSN. Some people do not have to give SSN’s to get help such as, victims of domestic
abuse, crime prosecution witnesses, and trafficking victims.
Overissuance
This means you got more CalFresh benefits than you should have. You will have to pay it back even if the County made an
error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of
benefits owed, through the courts, other collection agencies, or federal government collection action.
Reporting
Every household that gets CalFresh benefits must report certain changes. Your County will tell you what changes to report,
how to report them, and when to report them. Failure to report the changes may result in your CalFresh benefits being
lowered or stopped. You can also report if things happen that may increase your benefits, such as getting less income.
CF 285 (9/13)
11/19/2013 11:22 AM
p. 92
County of Orange
Bid 017-976001-GH
State Hearing
You have the right to a State hearing if you do not agree with any action taken regarding your application or your ongoing
benefits. You can request a State hearing within 90 days of the County’s action and you must tell why you want a hearing.
The approval or denial notice you receive from the County will have information on how to request a State hearing. If you
ask for a hearing before the action happens, you may be able to keep your CalFresh benefits the same until a decision is
made.
Nondiscrimination
It is the State and County’s policy that all people be treated equally, and with respect and dignity. In accordance with federal
law and the U.S. Department of Agriculture (USDA) policy, discriminating on the basis of race, color, national origin, sex,
age, religion, political beliefs, or disabilities is strictly prohibited.
To file a complaint of discrimination, either contact your County’s Civil Rights Coordinator, or write to or call the USDA or
California Department of Social Services (CDSS):
USDA, Director
Whitten Building
1400 Independence Ave. S.W.
Washington D.C. 20250-9410
1-202-720-5964 (voice and TDD)
CDSS
Civil Rights Bureau
P.O. BOX 944243, M.S. 8-16-70
1-866-741-6241 (Toll Free)
USDA is an equal opportunity employer.
Privacy Act and Disclosure
You are giving personal information in the application. The County uses the information to see if you are eligible for benefits.
If you do not give the information, the County may deny your application. You have a right to review, change, or correct any
information that you gave to the County. The County will not show your information or give it to others unless you give them
permission or federal and State law allows them to do so. The County will verify this information through computer matching
programs, including the Income and Earnings Verification System (IEVS). This information will be used to monitor compliance
with program regulations and for program management. The County may share this information with other federal and State
agencies for official examination, law enforcement officials for the purpose of arresting persons fleeing to avoid the law, and
private claims collection agencies for claims collection action. The County may verify immigration status of household
members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your
eligibility and level of benefits.
Case File Reviews
Your case may be selected for additional review to ensure that your eligibility was correctly figured. You must cooperate fully
with the County, State, or federal personnel in any investigation or review, including a quality control review. Failure to
cooperate in these reviews could result in loss of your benefits.
Work Rules for CalFresh
The County may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you
have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.
You may not be eligible for CalFresh if you have recently quit a job.
EBT Usage
Any benefit taken from your account before you, another household member, or your authorized representative report the
EBT card or PIN has been lost or stolen will not be replaced.
Any use of your EBT card by you, a household member, your authorized representative, or anyone you voluntarily give your
EBT card and PIN to will be considered approved by you and any benefits taken from your account will not be replaced.
If you do not report that another person you do not want to spend your benefits has your PIN and you do not get your PIN
CF 285 (9/13)
11/19/2013 11:22 AM
p. 93
County of Orange
Bid 017-976001-GH
NOTES
CF 285 (9/13)
11/19/2013 11:22 AM
p. 94
County of Orange
Bid 017-976001-GH
Please use black or blue ink because it is easy to read and copies best. Please print your answers.
If you need more space to answer a question(s), use page 10 “Additional Writing Space” section and attach additional sheets of
paper if needed to provide the information. Please be sure to identify which question you are writing about in the extra space
or on the additional sheets of paper.
1. APPLICANT’S INFORMATION
NAME (FIRST, MIDDLE, LAST)
OTHER NAMES (MAIDEN, NICKNAMES, ETC.)
SOCIAL SECURITY NUMBER (IF YOU HAVE
ONE AND ARE APPLYING FOR BENEFITS)
HOME ADDRESS OR DIRECTIONS TO YOUR HOME
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
STATE
ZIP CODE
HOME PHONE
EMAIL ADDRESS
WORK/ALTERNATE/MESSAGE PHONE
I want to get messages about my case by email.
■
Yes
■
No
Are you homeless? ■ Yes ■ No
If yes, please let the County know right away if you are homeless, so they can help you figure out
an address to use to accept your application and get notices from the county about your case.
What language do you prefer to read (if not English)?__________________________
What language do you prefer to speak (if not English)?_________________________
The County will provide an interpreter at no cost to you. If you are deaf or hard of hearing please check here
■
Do you have a disability and need help with applying?
■
Yes
■
No
Are you interested in applying for Medi-Cal? If you answer yes the County will use your answers to
find out if you can get Medi-Cal.
■
Yes
■
No
Is your household’s monthly gross income less than $150 and cash on hand, or in checking and
savings accounts is $100 or less?
■
Yes
■
No
Is your household’s combined monthly gross income and cash on hand or in checking and savings accounts
is less than the combined cost of rent/mortgage and utilities?
■
Yes
■
No
Is your household a migrant/seasonal farm worker household with liquid resources not exceeding
$100 and either your income stopped or you will not get more than $25 in the next 10 days?
■
Yes
■
No
I understand that by signing this application under penalty of perjury (making false statements), that:
• I read, or had read to me, the information in this application and my answers to the questions in this application.
• My answers to the questions are true and complete to the best of my knowledge.
• Any answers I may give for my application process will be true and complete to the best of my knowledge.
• I read or had read to me and I understand and agree to the Rights and Responsibilities (Program Rules Page 1) for the CalFresh
Program.
• I read, or had read to me, the CalFresh Program Rules and Penalties (Program Rules Pages 2 through 3).
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for
CalFresh is fraud. Fraud can cause a criminal case to be filed against me and/or I may be barred for a period of time (or life) from
getting CalFresh benefits.
• I understand that Social Security Numbers or immigration status for household members applying for benefits may be shared with
the appropriate government agencies as required by federal law.
SIGNATURE OF APPLICANT(OR ADULT HOUSEHOLD MEMBER/ AUTHORIZED REPRESENTATIVE*/GUARDIAN)
DATE
*If you have an Authorized Representative please complete question 2 on the next page.
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 1 OF 10
p. 95
County of Orange
Bid 017-976001-GH
2. HOUSEHOLD’S AUTHORIZED REPRESENTATIVE
You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for you at
the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may get by
mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be replaced. If you
are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.
Do you want to name someone to help you with your CalFresh case?
■
Yes
AUTHORIZED REPRESENTATIVE NAME:
■
No
AUTHORIZED REPRESENTATIVE PHONE NUMBER:
Do you want to name someone to receive and spend CalFresh benefits for your household?
NAME:
■
■
Yes
No
PHONE NUMBER:
ADDRESS:
CITY
STATE
ZIP CODE
3. RACE/ETHNICITY
Race and ethnicity information is optional. It is requested to assure that benefits are given without regard to race, color, or national origin.
Your answers will not affect your eligibility or benefit amount. Check all that apply to you. The law says the County must record your ethnic
group and race.
■
Check this box if you do not want to give the County information about your race and ethnicity. If you do not, the County will
enter this information for civil rights statistics only.
If you are of Hispanic or Latino origin, do you consider yourself:
ETHNICITY
■
Are you Hispanic or Latino?
Yes
■
■ Mexican
■ Puerto Rican
■ Cuban
■ Other___________________________________________
No
RACE/ETHNIC ORIGIN
■ White ■ American Indian or Alaskan Native ■ Black or African American ■ Other or Mixed __________________
■ Asian (If checked, please select one or more of the following):
■ Filipino ■ Chinese ■ Japanese ■ Cambodian ■ Korean ■ Vietnamese ■ Asian Indian ■ Laotian
■ Other Asian (specify)________________________________________
■ Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following): ■ Native Hawaiian
■ Guamanian or Chamorro ■ Samoan
4. INTERVIEW PREFERENCE
You will need to have an interview with the County to discuss your application and to receive CalFresh benefits.
Interviews for CalFresh are usually done by phone, unless you can be interviewed when giving your application to the County in person
or would prefer an in-person interview. In-person interviews will only happen during the County’s normal office hours.
■
■
Please check this box if you would prefer an in-person interview.
Please check this box if you need other arrangements due to a disability.
Please check the boxes below for your preferred day and time for an interview:
Day:
■ Today
Time:
■
■
Next available day
Early morning
■
■
Mid-morning
Any day
■
■
Afternoon
Monday
■
■
Tuesday
Late afternoon
■
■
Wednesday
■
Thursday
■
Friday
Anytime
5. OTHER PROGRAMS
Has anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Medicaid, Supplemental Nutrition
Assistance Program [Food Stamps], General Assistance (GA)/General Relief (GR), etc.)?
■
Yes
IF YES, WHO?
IF YES, WHO?
CF 285 (9/13)
11/19/2013 11:22 AM
■
No
PAGE 2 OF 10
p. 96
County of Orange
Bid 017-976001-GH
6a. HOUSEHOLD’S INFORMATION
Complete the following information for all persons in the home that you buy and prepare food
with, including you. If applying for noncitizens, please complete question 6b and 6c. If
not, go to question 6d.
APPLYING
FOR
BENEFITS
(✔ check Yes
or No)
NAME
(Last, First, Middle Initial)
How is the
person
related to
you?
Social Security number is optional for
members not applying for benefits. You
must answer the questions below for
each person applying for benefits.
U.S.
CITIZEN or
NATIONAL
(✔ check Yes
DATE
GENDER
or No)
OF BIRTH (M OR F)
If no,
complete
question 6b
below
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
■
Yes ■ No
SOCIAL SECURITY
NUMBER
Please list the names of anyone who lives with you that does not buy and prepare food with you:
NAME
NAME
NAME
NAME
6b. NONCITIZEN INFORMATION - Complete for those listed in question 6a above who are not citizens and are applying for aid.
Name
Date of Entry
into U.S.
(if known)
Sponsored?
(✔ check Yes or
No) If yes,
complete
question 6c
below:
Give one of the following (if known):
Passport Number,
Alien Registration Number, etc.
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
DOCUMENT TYPE:_________________________________________________
DOCUMENT NUMBER:______________________________________________
DOCUMENT TYPE:__________________________________________________
DOCUMENT NUMBER:_______________________________________________
Does anyone listed above have at least 10 years (40 quarters) of work history or military service in the USA?
■
Yes ■ No
■
Yes ■ No
■
■
Yes ■ No
■
Yes ■ No
Yes ■ No
If yes, who?____________________________________________________________________________
Does anyone listed above have, or have they applied for, or do they plan to apply for a T-Visa or
U-Visa, VAWA petition?
If yes, who?_______________________________________________________________________________________________
6c. SPONSORED NONCITIZEN INFORMATION - Complete for those listed in question 6b above who are sponsored noncitizens and
are applying for aid.
Did the sponsor sign an I-864? ■ Yes ■ No If yes, please answer the rest of the question. If the sponsor signed an I-134 then
skip this question.
Does the sponsor regularly help with money?
■
Yes ■ No If yes, how much? $____________
Does the sponsor regularly help with any of the following (check all that apply)?
rent
■ clothes ■ food ■ other___________________________________________________________
■
SPONSOR’S NAME
WHO IS SPONSORED?
SPONSOR’S NAME
WHO IS SPONSORED?
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 3 OF 10
p. 97
County of Orange
Bid 017-976001-GH
6d. Students
Is anyone who is applying for benefits attending a college or vocational school?
question.
If no, skip to the next question.
Name of Person
■ Yes ■ No
If yes, please answer this
Enrolled Status
(✔ check one)
Name of School/Training
■
■
Half-time or more
Less than half-time
■
■
Half-time or more
Less than half-time
Are They Working?
Average work hours
per week:________
Average work hours
per week:________
6e. Is there a foster child living in your home? ■ Yes ■ No If yes, who?_________________________________________
Please answer the following questions about the child(ren):
■ Yes ■ No
Was this child(ren) placed in your home under a dependence order of the court?
■ Yes ■ No
Do you want the foster care child(ren) counted in your CalFresh case? If yes, the foster care
income you receive will be counted as unearned income. If no, the foster care income will not
be counted as unearned income.
7.
Unearned Income
Does anyone you buy and prepare food with get income that does not come from work (unearned)? ■ Yes
Check all types of unearned income that apply from these examples (there may be others not listed here):
■
■
■
■
■
■
■
■
Social Security
SSI/SSP
Cash aid
CalWORKs/TANF/GA/GR/CAPI
Room and board (from your renter)
Pension
Child/Spousal support
■
■
■
■
■
Veteran benefits, or Military pension
Financial aid (school grants/loans/
scholarships)
Gift of money
Unemployment Insurance/
State Disability Insurance (SDI)
Worker’s compensation
Lottery/gambling winnings
Help with rent/food/clothing
Insurance or legal settlements
Private disability or retirement
Strike benefits
Other____________________
_________________________
Government/railroad disability or
retirement
Person getting the money?
■
■
■
■
■
■
■ No
How
much?
From where?
How often received?
(once, weekly, monthly, or
other)
Expect to
continue?
(✔ Check
Yes or No)
$
■ Yes ■ No
$
■ Yes ■ No
$
■ Yes ■ No
$
■ Yes ■ No
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 4 OF 10
p. 98
County of Orange
8.
Bid 017-976001-GH
Earned income
Does anyone you buy and prepare food with have income from a job (earned income)? ■ Yes ■ No
If yes, please answer this question. If no, skip to the question 9.
NOTE: If self-employed fill out question 8a.
Please list all income before taxes or other deductions are taken out (gross income).
Examples of earned income are (these examples can be full-time, temporary, seasonal, or training, and there may be others not
listed here):
● Work study (students)
Salaries
●
Tips
●
Commissions
●
Wages
●
Employer’s name and Employer’s
address
phone number
Person working
Hourly
rate
How often
Average
paid?
hours per
(Once weekly,
week
monthly, other)
Total gross
earned
income
received
this
month
$
$
$
$
$
$
$
$
Expect to
continue?
(✔ Check
Yes or No)
■ Yes
■ No
■ Yes
■ No
■ Yes
■ No
■ Yes
■ No
Has anyone lost a job, changed jobs, quit a job, or reduced work hours within the last 60 days?
IF YES, WHO?
■ Yes ■ No
DATE OF JOB LOSS, QUIT, OR CHANGE
DATE OF LAST PAY
DATE WENT ON STRIKE
DATE OF LAST PAY
REASON?
Is anyone on strike?
■ Yes ■ No
IF YES, WHO?
REASON?
8a. Self-Employment
Self-employed household members may deduct actual self-employment expenses or take a standard 40% deduction off of
self-employment income. If you choose actual expenses, you will need to give the County proof of the expenses.
Person
self-employed
Date business
started
Gross
monthly
income
Type of business and name
$
$
$
$
$
CF 285 (9/13)
11/19/2013 11:22 AM
Self-employment expenses
(please ✔ check one)
■
■
■
■
■
■
■
■
■
■
40% flat rate
40% flat rate
40% flat rate
40% flat rate
40% flat rate
PAGE 5 OF 10
p. 99
County of Orange
9.
Bid 017-976001-GH
Household’s Child/Adult Care Expenses
Do you or anyone you buy and prepare food with pay for the care of a child, disabled adult,
or other dependent so you or the other person can go to work, school, training, or look for a job?
■ Yes ■ No
Who gives care?
(name and address of provider)
Who gets care?
Amount
paid?
How often
paid?
(weekly/monthly,
other)
$
$
$
$
Does anyone help your household pay all or part of your child/adult care costs listed above?
■ Yes ■ No
Who helps pay?
Who gets care?
If yes, complete below:
Amount
paid?
How often
paid?
(weekly/monthly,
other)
$
$
10. Child Support Payments
Are you or anyone you buy and prepare food with legally obligated to pay child support,
including back child support? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
Who pays child support?
Amount
paid?
Name of child(ren) for whom child support is paid:
How often paid
(weekly/monthly,
other)
$
$
11. Household Expenses
Are you or anyone you buy and prepare food with responsible for any household expenses? ■ Yes ■ No If yes, please answer
this question. If no, skip to the next question.
NOTE: Do not enter amounts paid by housing assistance such as HUD or Section 8. The heating and cooling, telephone, other
utilities, and the homeless shelter are set allowances and you do not need to fill in the actual amount owed.
How often billed?
Amount
Have
Type of Expenses
Who pays?
(weekly/monthly)
Owed
Expense?
$
Rent or house payment
■ Yes ■ No
Property taxes and insurance (if billed separately from
$
rent or mortgage)
■ Yes ■ No
Gas, electric, or other fuel used for heating or cooling,
such as firewood or propane (if billed separately from ■ Yes ■ No
rent or mortgage)
Telephone/cell phone
Homeless Shelter Expense
Water, sewage, garbage
Does anyone not in your household help you pay for the
expenses listed above? ■ Yes ■ No If yes, please
complete.
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
Who helps pay?
How much?
$
How often paid?
Does your household receive, or expect to receive, payment from the Low Income Home Energy Assistance
Program (LIHEAP)?
■ Yes ■ No
CD 285 (9/13)
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PAGE 6 OF 10
p. 100
County of Orange
Bid 017-976001-GH
12. Medical Expenses:
Are you or anyone you buy and prepare food with an elderly (60 or older) or disabled person that has any out-of-pocket medical
expenses? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
NOTE: Do not list spouses or children receiving dependent payments for an SSI or disability and blindness recipient.
List expenses you expect to have in the near future.
Allowable medical expenses are:
■
■
■
■
■
Medical or dental care
Hospitalization/outpatient
treatment/nursing care
■
■
Prescribed medications
Health and Hospitalization
insurance policy premiums
■
■
Medicare premiums (Medi-Cal share of
costs, etc.)
Dentures, hearing aids and prosthetics
Maintaining an attendant necessary due
to age, illness, or infirmity
The number and cost of meals
furnished to an attendant
Prescribed over the counter medications
Amount of
expense
Name of elderly/disabled person
■
■
■
■
Cost of transportation (mileage or fee)
and lodging to obtain medical treatment
or services
Prescribed eye glasses and contact
lenses
Prescribed medical supplies and
equipment
Service animals expenses
(food, vet bills, etc.)
What type of
Will the household be reimbursed
How often
expense?
for any medical expenses?
paid?
(prescriptions,
(by Medi-Cal, insurance,
dentures,
(monthly, weekly,
number of meals for
family member, etc.)
other)
attendant, etc.)
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
IF YES, BY WHO:
$
HOW MUCH: $
13. Does anyone get food from any of the following?
question.
● Communal dining facility for the elderly/disabled
■ Yes ■ No
●
Food distribution program operated
by a Native American reservation
IF YES, WHO?
WHERE?
IF YES, WHO?
WHERE?
14. Does anyone live at any of the following?
●
●
●
●
●
■ Yes ■ No
Homeless Shelter
Shelter for battered women
Reservation for Native Americans
Drug/Alcohol rehabilitation center
Correctional facility/Penal institution (Jail or Prison)
Person’s Name
If yes, please answer this question. If no, skip to the next
●
Other food program
●
●
●
●
●
Group living arrangement for the blind/disabled
Federally subsidized housing
Psychiatric hospital/mental institution
Hospital
Long-Term Care or Board and Care Facility
Name of Institution (center, shelter, facility, etc.)
Expected Date of Release
(if applicable)
15. Is anyone living with you age 60 or older and unable to buy food and fix meals separately
because of a disability?
■ Yes ■ No
IF YES, WHO?
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 7 OF 10
p. 101
County of Orange
Bid 017-976001-GH
16.
Household’s Resources
Do you or anyone you buy and prepare food with have any resources (cash, money in the bank, Certificate of Deposit,
stocks and bonds, etc.)? ■ Yes ■ No If yes, please answer this question. If no, skip to the next question.
Check each resource listed below:
■
■
■
■
Bank/Credit Union account (Checking)
Bank/Credit Union account (Saving)
Safe Deposit box
Savings Bond(s)
■
■
■
■
Money Market Account
Mutual Funds
Certificate of Deposit (CD)
Cash on hand
■
■
■
Stocks
Bonds
Other: ____________________
If joint account with another person please say so below.
For each box checked above, complete the following information.
In whose name is the
resource listed?
What type of resource?
How much is
it worth?
Where is the resource?
(include the name of the bank or company
where money is held)
$
$
$
$
Have you or anyone in your household sold, traded, given away, or transferred a resource in the last three months?
17.
18.
19.
20.
21.
22.
Duplicate Benefits
Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP
(federal name for food assistance program, known as CalFresh in California) benefits in any state
If yes, who?_______________________________________________________________
Trafficking Benefits
Have you or any member of your household ever been convicted of trafficking (allowing use of or
selling EBT cards to others) SNAP benefits of $500 or more after September 22, 1996?
If yes, who?_______________________________________________________________
Trading Benefits for Drugs
Have you or any member of your household been found guilty of trading SNAP benefits for drugs
If yes, who?_______________________________________________________________
Trading Benefits for Firearms or Explosives
Have you or any member of your household been found guilty of trading SNAP benefits for guns,
ammunition, or explosives after September 22, 1996?
If yes, who?_______________________________________________________________
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
■ Yes ■ No
Fleeing Felon
Are you or any member of your household hiding or running from the law to avoid prosecution, being
taken into custody, or going to jail for a felony crime or attempted felony crime?
If yes, who?_______________________________________________________________
■ Yes ■ No
Probation/Parole Violation
Have you or any member of your household been found by a court of law to be in violation of
probation or parole?
If yes, who?_______________________________________________________________
■ Yes ■ No
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 8 OF 10
p. 102
County of Orange
23.
Bid 017-976001-GH
Drug Felony
Have you or any member of your household, been convicted of felony possession, use, or distribution of
a controlled substance (illegal drugs or certain drugs for which a doctor’s prescription is required) after
August 22, 1996?
If yes, and the felony conviction was for possession, have you or that household member done
(or will do) any of the following:
■ Yes ■ No
a) Completed a government-recognized drug treatment program?
■ Yes ■ No
b) Participated in a government-recognized drug treatment program?
■ Yes ■ No
c) Enrolled in a government-recognized drug treatment program?
■ Yes ■ No
d) Been placed on a waiting list for a government-recognized drug treatment program?
■ Yes ■ No
e) Stopped the use of controlled substances and have evidence that you have stopped?
■ Yes ■ No
If yes, please explain:_______________________________________________________________
________________________________________________________________________________
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 9 OF 10
p. 103
County of Orange
Bid 017-976001-GH
DO NOT COMPLETE - COUNTY USE ONLY
■ Yes ■ No
Is the household’s combined gross income and cash on hand or on checking and savings accounts
■ Yes ■ No
■ Yes ■ No
CF 285 (9/13)
11/19/2013 11:22 AM
PAGE 10 OF 10
p. 104
County of Orange
Bid 017-976001-GH
NӃu quý vӏ chѭa ghi danh bӓ phiӃu tҥi nѫi quý vӏ sinh sӕng hiӋn nay,
quý vӏ có muӕn ghi danh bӓ phiӃu ӣ ÿây hôm nay hay không?
(Ĉánh Dҩu Vào Mӝt Ô)
Ĉã ghi danh.
Tôi ÿã ghi danh bӓ phiӃu tҥi ÿӏa chӍ cѭ ngө hiӋn nay cӫa tôi.
Có.
Tôi muӕn ghi danh bӓ phiӃu. (Xin ÿiӅn thҿ ghi danh cӱ tri ÿính kèm.)
Không.
Tôi không muӕn ghi danh bӓ phiӃu.
GHI CHÚ: NӂU QUÝ Vӎ KHÔNG ĈÁNH DҨU VÀO MӜT Ô, QUÝ Vӎ SӀ ĈѬӦC XEM LÀ QUYӂT ĈӎNH KHÔNG GHI
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DANH BҨT CӬ LÚC NÀO TIӊN CHO QUÝ Vӎ.
Tên Ĉѭѫng Ĉѫn
Ngày
Các Thông Báo Quan Trӑng
1. ViӋc nӝp ÿѫn xin ghi danh hoһc tӯ chӕi ghi danh bӓ phiӃu sӁ không ҧnh hѭӣng ÿӃn mӭc trӧ giúp mà quý vӏ sӁ ÿѭӧc cѫ
quan này cung cҩp.
2. NӃu quý vӏ muӕn ÿѭӧc giúp ÿiӅn mүu ÿѫn ghi danh cӱ tri, chúng tôi sӁ giúp quý vӏ. Tùy quý vӏ quyӃt ÿӏnh có muӕn nhӡ giúp
hay chҩp nhұn ÿѭӧc giúp hay không. Quý vӏ có thӇ ÿiӅn mүu ÿѫn trong chӛ riêng tѭ.
3. NӃu quý vӏ tin rҵng có ngѭӡi ÿã xâm phҥm ÿӃn quyӅn ghi danh hoһc tӯ chӕi ghi danh bӓ phiӃu, quyӅn riêng tѭ cӫa quý vӏ
ÿӇ quyӃt ÿӏnh có ghi danh hoһc nӝp ÿѫn ghi danh bӓ phiӃu hay không, hoһc quyӅn chӑn chính ÿҧng hoһc chӑn lӵa chính trӏ
nào khác cӫa mình, quý vӏ có thӇ nӝp ÿѫn khiӃu nҥi vӟi Tәng Thѭ Ký TiӇu Bang bҵng cách gӑi sӕ miӉn phí (800) 339-8163
hoһc quý vӏ có thӇ viӃt thѭ ÿӃn: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. Muӕn biӃt thêm chi tiӃt vӅ
các cuӝc bҫu cӱ và bӓ phiӃu, xin ÿӃn website cӫa Tәng Thѭ Ký TiӇu Bang tҥi www.sos.ca.gov.
01/13 NVRA Voter Preference Form – Vietnamese
11/19/2013 11:22 AM
p. 105
County of Orange
Bid 017-976001-GH
DO YOU KNOW?
Your Family May Qualify For Medi-Cal
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11/19/2013 11:22 AM
p. 107
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 108
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 109
County of Orange
Bid 017-976001-GH
CALFRESH BENEFITS
sure how to report changes, what changes to report, or what proof we need, be sure to ask your local county office. You
are receiving this notice because:
■ You have been approved for CalFresh benefits and will be reporting changes on a Semi-Annual basis.
■ Your household was previously assigned Change Reporting status and will now be reporting on a Semi-Annual basis.
Semi-Annual Reporting requirements are described below.
SEMI-ANNUAL REPORTING
As a semi-annual reporting household, you will need to turn in a
completed Semi-Annual Report form (SAR 7) due by the 5th
day of the 6th month after your most recent certification. If you
do not turn in your completed SAR 7 by the end of the first
working day of the next (7th) month, your benefits will stop.
Your worker will use the income and expense information
reported on the SAR 7 to calculate your CalFresh benefits for
the remainder of the certification period.
For example:
You completed your annual recertification in May. Your SAR 7
will be due 6 months later, on November 5th and you will report
what income you had in October. You will also report any
income changes you expect to have in December, January,
February, March, April and May. You must turn in your
completed SAR 7 by no later than the first working day in
December or your benefits will stop. You will lose benefits
unless you had a good reason for being late. Your annual
recertification will be due in May six months later. Your next
SAR 7 will be due for the following certification period six
months later.
What you must report on a
Semi-Annual Report (SAR 7):
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Earned income from any source;
Unearned income of any kind;
Anyone getting free rent or utilities;
Anyone who has expenses that are paid by someone else;
Reduced hours of work or training;
Someone moves in/out of your home;
If you move;
Any real or personal property bought, sold or exchanged;
Any change in legally obligated child support paid by a
household member;
Anyone’s citizenship/immigration status changes or
receives correspondence from the U.S. Citizenship and
Immigration Services (USCIS) (formerly INS);
Anyone reaches 60 years of age;
Anyone gets a job or payments for training or school
expenses;
Anyone has a job, training or school costs such as for
dependent care or supplies;
manufacturing, sale , or distribution of a controlled
REPORTING MANDATORY CHANGES DURING THE
CERTIFICATION PERIOD
You must report the following changes within ten (10) days even
if it is not your report month. You are to report:
•
•
When your household’s income is more than 130% of
federal poverty level, for your household size (CalFresh
IRT).
•
Living in a county where the ABAWD work rule is
•
Under 18 or 50 years of age or older;
•
Medically certified as physically or mentally unfit for
employment;
•
Meeting the CalWORKs Welfare-To-Work rules;
•
Caring for an injured or sick person who will need help
•
Participating in an alcohol or drug treatment program
week;
•
Getting or have applied for Unemployment Insurance
benefits.
REPORTING VOLUNTARY CHANGES
You may also report other information voluntarily, even when it is
not your report month. Reporting information voluntarily may
cause your household benefits to go up or down. See examples
below. The county will take action within ten (10) days after you
provide verification. One exception is when the increase results
from adding another person to your case. In that situation, the
county will take action to increase benefits the first of the month
after you provide verification. Even if you have already
reported something to the County, you must also report it
on your next SAR 7 or recertification.
benefits to go up include:
•
Loss of income;
•
Member becomes disabled or 60 years old;
•
Member begins to pay court-ordered child support;
•
New household member in the home;
•
Shelter/housing cost increases;
•
Medical expenses.
(Continued on back)
11/19/2013 11:22 AM
p. 110
County of Orange
Bid 017-976001-GH
REPORTING VOLUNTARY CHANGES - Continued
benefits to go down include:
•
Gain or increase of income that is less than your CalFresh
IRT;
•
Someone with no income moves out of your home;
•
Someone in your home who had no income dies;
•
Someone with income moves into your home;
•
Shelter cost decrease.
benefits for five months to households that leave CalWORKs.
You MAY report changes during your households certification
period either by:
•
If your household begins receiving transitional CalFresh
benefits, you do not have to report while receiving these
benefits.
If you are receiving Transitional CalFresh benefits, you may
Mail, telephone or in person at the county CalFresh office
or by turning in a Mid-Certification Period Status Report or
SAR 3.
OTHER CHANGES
There are other circumstances that will require the county to
decrease or discontinue your benefits during the certification
period in which they happen. Here are some examples:
•
A household member is sanctioned;
•
Someone in your household receives benefits in another
household;
•
A California Food Assistance Program status changes.
11/19/2013 11:22 AM
p. 111
County of Orange
Bid 017-976001-GH
CALFRESH BENEFITS
Reporting basis.
CHANGE REPORTING
•
•
•
•
•
•
•
•
living in the home.
employment’
week;
benefits;
• Pregnant; or
benefits.
•
•
•
•
•
•
•
•
•
Office; or
Report form.
11/19/2013 11:22 AM
p. 112
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 113
County of Orange
Bid 017-976001-GH
THÔNG TIN QUAN TRӐNG - VUI LÒNG ĈӐC KӺ
Các Yêu Cҫu Báo Cáo Mӟi Ĉӕi Vӟi Trӧ Cҩp TiӅn Mһt và CalFresh
Quұn/hҥt ÿang trong quá trình ÿәi tӯ chӃ ÿӝ
Báo Cáo Hàng Quý (mӛi ba tháng) thành Báo
Cáo Bán Niên (mӛi sáu tháng). Dѭӟi ÿây là
các thay ÿәi sҳp thӵc hiӋn. Chúng tôi sӁ thông
báo cho quý vӏ biӃt khi phҧi bҳt ÿҫu theo các
quy ÿӏnh mӟi.
Các Thay Ĉәi Ĉӕi Vӟi Quy Ĉӏnh vӅ Mӭc
Trҫn Thu Nhұp Phҧi Báo Cáo (Income
Reporting Threshold - IRT)
Mӭc IRT là tәng sӕ thu nhұp hàng tháng quý vӏ
phҧi báo cáo trong vòng 10 ngày. Khi dùng tӯ
"tәng sӕ thu nhұp hàng tháng" tҥi ÿây thì có
nghƭa là toàn bӝ sӕ tiӅn quý vӏ nhұn ÿѭӧc.
Quұn/Hҥt sӁ báo cáo bҵng văn bҧn mӛi khi
mӭc IRT cӫa quý vӏ thay ÿәi.
Mүu Báo Cáo
Trѭӟc ÿây, quý vӏ ÿѭӧc yêu cҫu nӝp mүu QR
7 mӛi 3 tháng. Sҳp tӟi quý vӏ sӁ chӍ cҫn nӝp
mүu báo cáo mӝt lҫn mӛi 6 tháng.
Ĉӕi Vӟi Trӧ Cҩp TiӅn Mһt: Sӕ thu nhұp quý vӏ
phҧi báo cáo trong vòng 10 ngày sҳp thay ÿәi.
Mӭc IRT căn cӭ vào tәng sӕ thu nhұp cӫa quý
vӏ cǊng nhѭ sӕ ngѭӡi sӕng trong gia hӝ. Trѭӟc
ÿây, khi tәng sӕ thu nhұp cӫa quý vӏ vѭӧt mӭc
IRT thì chúng tôi phҧi cҳt trӧ cҩp cho quý vӏ.
ChiӃu theo quy ÿӏnh mӟi, khi quý vӏ báo cáo sӕ
thu nhұp vѭӧt mӭc IRT thì quұn/hҥt có thӇ
giҧm hoһc có thӇ cҳt trӧ cҩp cӫa quý vӏ.
Mүu báo cáo 6 tháng ÿѭӧc gӑi là SAR 7.
Còn mүu báo cáo kia là mүu xác nhұn/chӭng
nhұn lҥi tính hӝi ÿӫ ÿiӅu kiӋn hàng năm
(redetermination/recertification hay gӑi tҳt là
RD/RC).
Hҥn nӝp mүu SAR 7 luôn là 6 tháng sau khi
nӝp mүu RD/RC hàng năm, vào ngày thӭ 5
cӫa tháng ÿó. NӃu quý vӏ không nӝp mүu SAR
7 hoàn chӍnh trѭӟc khi hӃt giӡ vào ngày làm
viӋc ÿҫu tiên cӫa tháng kӃ tiӃp (tháng thӭ 7),
thì trӧ cҩp cӫa quý vӏ sӁ bӏ ngӯng.
Thí dө: NӃu quý vӏ ÿѭӧc quy ÿӏnh mӭc IRT là
$900 và có thu nhұp là $800, quý vӏ có thӇ chӡ
ÿӃn ngày nӝp báo cáo tӟi thì mӟi cҫn báo cáo
thay ÿәi ÿó. Còn nӃu thu nhұp cӫa quý vӏ ÿҥt
tӯ $901 trӣ lên thì quý vӏ phҧi báo cáo thu
nhұp cho cán sӵ xã hӝi biӃt trong vòng 10
ngày. Trӧ cҩp cӫa quý vӏ sӁ bӏ giҧm và cán sӵ
xã hӝi sӁ cho biӃt mӭc IRT mӟi là gì.
Thí dө: Quý vӏ hoàn tҩt thӫ tөc RD/RC hàng
năm vào Tháng Hai. Thӡi hҥn nӝp mүu SAR 7
là sau ÿó 6 tháng, vào mùng 5 Tháng Tám.
Quý vӏ phҧi nӝp mүu SAR 7 hoàn chӍnh cho
cán sӵ xã hӝi cӫa quý vӏ không trӉ hѫn ngày
làm viӋc ÿҫu tiên cӫa Tháng Chín, nӃu không
quý vӏ sӁ bӏ cҳt trӧ cҩp. Quý vӏ sӁ bӏ mҩt trӧ
cҩp nӃu không có lý do chính ÿáng khiӃn cho
quý vӏ phҧi nӝp mүu trӉ hҥn.
Ĉӟi Vӟi Chѭѫng Trình CalFresh: Trѭӟc ÿây,
quý vӏ không có mӭc IRT trong chѭѫng trình
này. Sҳp tӟi quý vӏ sӁ ÿѭӧc quy ÿӏnh mӭc IRT
dӵa vào sӕ ngѭӡi trong gia ÿình. Khi quý vӏ
báo cáo sӕ thu nhұp vѭӧt mӭc IRT thì
quұn/hҥt có thӇ ngѭng trӧ cҩp cӫa quý vӏ.
Giӕng nhѭ khi ÿiӅn vào mүu QR 7, quý vӏ phҧi
trҧ lӡi tҩt cҧ các câu hӓi trên mүu SAR 7, ÿính
kèm các chӭng cӟ, ký tên và ÿӅ ngày rӗi gӱi
lҥi trѭӟc ngày ghi trong mүu báo cáo.
Các Quy Ĉӏnh vӅ ViӋc Báo Cáo Bҳt Buӝc và
Báo Cáo Tӵ NguyӋn vүn nhѭ trѭӟc. NӃu tӵ
nguyӋn báo cáo thay ÿәi, quý vӏ có thӇ ÿѭӧc
tăng trӧ cҩp.
TEMP SAR 1 (VN) (10/12) NEW REPORTING REQUIREMENTS FOR CASH AID AND CALFRESH
11/19/2013 11:22 AM
p. 114
County of Orange
11/19/2013 11:22 AM
Bid 017-976001-GH
p. 115
Xây d̤ng Tˍˌng lai T̔t
Xây dựng Tương lai Tốt
ê̈p hˌn cho Gia êi`nh B˼n
đẹp hơn cho Gia đình Bạn
Hãy nhận phúc lợi của dịch vụ kế
hoạch hóa gia đình, dịch vụ này có
thể giúp bạn:
• Cải thiện khả năng tự chủ của bạn
bằng cách ngừa thụ thai ngoài dự tính.
• Hãy dự tính số con và khoảng cách
tuổi giữa chúng để bạn có thể đáp ứng
các nhu cầu kinh tế và tình cảm của
gia đình bạn.
• Hãy trao đổi với người bạn đời của
bạn về các vấn đề sức khỏe sinh sản.
• Hãy nói với các con bạn về tình dục
an toàn và cách ngừa thai.
Hãy làm vì bản thân bạn. Hãy
Hãy làm vì bản thân bạn. Hãy
làm vì những người ta yêu quý.
làm vì những người ta yêu quý.
Hộp Tem của Hạt
Dịch vụ Giới thiệu và Thông tin Kế
hoạch hóa Gia đình của California
1-800-942-1054
State of California
PUB 275 (VN) (04/07)
Kế hoạch hóa Gia đình…
ho˼ch hóa Gia êình…
HãyK̋
Cam
kết vì một Tương
Hãy Cam k̋t vì m̘t Tˍˌng
lailaiKhỏe
mạnh
Kh̓e m˼nh
p. 116
11/19/2013 11:22 AM
Bid 017-976001-GH
County of Orange
Kế hoạchạn
K̋ ho˼ch hóa Gia êình – Vì Tˍˌng lai Gia êình B˼n
• Hãy giải đáp mọi câu hỏi mà bạn
quan tâm về sức khỏe sinh sản.
• Hãy học cách tự kiểm tra để phát hiện
ung thư vú.
• Hãy xét nghiệm phát hiện ung thư
đường sinh sản.
• Hãy học cách tránh bị nhiễm và
truyền sang người khác các bệnh
truyền nhiễm đường sinh dục, kể cả
HIV/AIDS.
• Hãy xét nghiệm và chữa trị các bệnh
truyền nhiễm qua đường sinh dục.
• Hãy tìm hiểu về cách ngừa thai khẩn
cấp, và xem nó có phải là lựa chọn
đúng cho bạn không, và khi nào bạn
cần đến nó.
• Không đắt – người hưởng CalWORKs sẽ đượn hưởng miễn
phí và với giá rẻ.
• Dành cho nam và nữ giới, kể
cả thanh thiếu niên.
• Bí mật, nghĩa là chỉ được biết
riêng giữa bạn và bác sĩ của
bạn.
Các dịch vụ đó là:
Hãy cam k̋t ngay hôm nay.
Hãy cam kết ngay hôm nay.
1-800-942-1054
• Hãy gọi cho Dịch vụ Giới thiệu và Thông
tin Kế hoạch hóa Gia đình của California
để hỏi tên, địa chỉ và số điện thoại của
nhà cung cấp dịch vụ kế hoạch hóa gia
đình ở khu vực bạn, số máy là:
• Hãy xem các trang vàng điện thoại dưới
tiêu đề “Thông tin Kế hoạch hóa Gia
đình.”
• Từ bác sĩ của bạn, ban sức khỏe của
hạt hoặc chương trình chăm sóc sức
khỏe của bạn.
• tìm cách ngừa thai hợp với lối sống
của bạn. Có hàng loạt lựa chọn – từ
thuốc viên, vòng cho đến thuốc tiêm
chích, và nhiều cách khác.
• Hãy nhận các nguồn chu cấp ngừa
thai để tránh thụ thai ngoài dự tính.
Hãy dùng dịch vụ kế hoạch hóa gia
đình trong cộng đồng của bạn:
11/19/2013 11:22 AM
Nhà cung cấp kế hoạch hóa gia
đình nơi bạn ở có thể giúp bạn:
County of Orange
Bid 017-976001-GH
p. 117

Quý v không th i xe ln vào phòng khám,
phng vn hoc phòng v sinh.
Nam gi
i c gi
i thiu hun ngh cho các công
vic c tr lng cao hn n gi
i.
Qun/ht không mun quý v tham gia hun ngh
vì cho rng quý v ã “quá già”.
Quý v không c phép nhn nuôi mt a tr vì
quý v thuc mt chng tc khác.
KHIU NI VÌ B PHÂN BIT I X
Nu quý v cho rng mình b phân bit i x thì có th
np n khiu ni trc tip lên Qun/Ht hoc Tiu
Bang cng nh Chính Ph Liên Bang. Quý v phi
khiu ni lên úng C Quan Liên Bang có trách nhim
cho chng trình mà quý v mun khiu ni.
Quý v có th np n khiu ni b phân bit i x
lên:
1.
2.
3.
k[ th. Nu vic phân bit i x còn nh h@ng t
i các
quy'n li và dch v? quý v áng c h@ng thì quý
v cng phi xin mt phiên i'u trJn tiu bang trong
vòng 90 ngày. Mt cuc i'u tra v' phân bit i x
không th thay Zi các mc quy'n li hay dch v? ca
quý v…ch* mt phiên i'u trJn tiu bang m
i có th
làm c i'u này.
GII HN V MT S QUYN
Mc dù quý v có quy'n c bo v s riêng t và bo
mt thông tin nhng có lut cho phép mt s ít tr=ng
hp ngoi l. Quý v có th hi qun v' nhng lut này.
CÂU HI
Nu quý v có bt k[ câu hi nào v' các quy'n c
lit kê @ ây, xin g;i Public Inquiry Unit (B Phn
Tip Nhn Th\c M\c ca Cng ]ng): s mi3n phí
(800) 952-5253. S in thoi TDD mi3n phí là (800)
952-8349.
T
THÔNG TIN NÀY DÀNH CHO CÁC
CHNG TRÌNH SAU
Adoption Assistance Program (AAP—Chng
Trình Tr Giúp Giao Nhn Con Nuôi)
Adult Protective Services (Dch V? Bo V Ng=i
Tr@ng Thành)
Alcohol and Drug Program (Chng Trình Cai
Ru và Ma Túy)
California Food Assistance Program (CFAP—
Chng Trình Tr Cp Thc Ph^m California)
Medi-Cal
CalWORKs
CalWORKs Child Care (Chng Trình Gi Tr
ca CalWORKs)
CalWORKs Welfare-to-Work Program/Services
(Chng Trình/Dch V? Chuyn T> Tr Cp Sang
Vic Làm ca CalWORKs)
Cash Assistance Program for Immigrants (CAPI—
Chng Trình Tr Cp Ti'n Mt cho Ng=i Nhp C)
Child Welfare Services (Dch V? An Sinh dành
cho Tr Em)
Denti-Cal
Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT—Khám Sàng L;c nh K[,
Ch^n oán và i'u Tr S
m)
CalFresh (Phiu Thc Ph^m)
Tr Cp Chm Sóc Tr Tm Nuôi

In-Home Support Services (Các Dch V? H` Tr
Ti Gia)
Kinship Gurdian Assitance (Kin-GAP—Tr Cp
Cho Thân Nhân Nhn Giám H Tr Em)
Chm Sóc Sc Khe Tâm ThJn
Multipurpose Senior Services Program (MSSP—
Chng Trình Các Dch V? a Ích Dành Cho
Ng=i Cao Niên)
Personal Care Services Program (PCSP—Chng
Trình Các Dch V? Chm Sóc Cá Nhân)
Refugee Cash Assistance (Tr Cp Ti'n Mt Cho
Ng=i T Nn)
Các Dch V? Xã Hi
STATE OF CALIFORNIA
(BANG CALIFORNIA)
HEALTH AND HUMAN SERVICES AGENCY
(C# QUAN Y Tj VÀ DwCH Vz NHÂN SINH)
DEPARTMENT OF SOCIAL SERVICES
(S$ DwCH Vz XÃ H%I)
Có th ly t= thông tin này @ Vn Phòng Tr Cp
ca Qun/Ht a Phng và ti a ch*
www.cdss.ca.gov bng các ngôn ng sau:
y !-rp
y Nht
y Nga
y Armenia
y Hàn
y Tây Ban Nha
y Kampuchia y Lào
y Tây Ban Nha Ch In To
y Trung Quc y Mien
y Tagalog
y U-crai-na
y Iran
y B] ào Nha
y Hmong
y Punjabi y Vit Nam
Cng có s}n bng ch in to, ch nZi, và ~a nghe
PUB 13 (Vietnamese) (6/11)
CÁC QUYN
CA QUÝ V
THEO CÁC CH"#NG TRÌNH
TR CP CA CALIFORNIA
Yêu cu thông dch viên
min phí
Hãy cho chúng tôi bit nu quý
v cn tr giúp do tình trng
khuyt t
t
……….dành cho nhng ai np
n xin hoc nhn tr cp xã hi
California
County of Orange
4.
I VI TT C! CÁC CH"#NG TRÌNH DO
S$ XÃ H%I QU&N QU!N LÝ: Civil Rights
Coordinator (i'u Phi Viên v' Quy'n Dân S)
ca Qun. Xin hi vn phòng qun bit tên, a
ch* và s in thoi ca i'u Phi Viên v' Quy'n
Dân S ca Qun.Ông/bà ta s+ c lp i'u tra
khiu ni ca quý v.
Civil Rights Bureau
744 P Street, MS 8-16-70
(916) 654-2107
(866) 741-6241 (Mi3n Phí Cuc G;i)
I VI CH"#NG TRÌNH CALFRESH:
Director, Office of Civil Rights
(202) 720-6382 (=ng dây nói và TTY)
I VI TT C! CÁC CH"#NG TRÌNH KHÁC:
Office of Civil Rights 90 7th Street, Suite 4-100
(415) 437-8310 (=ng dây nói)
(415) 437-8311 (=ng dây TDD)
GII HN TH
I GIAN HÀNH NG
Nu quý v b phân bit i x thì phi np n khiu
ni trong vòng 180 ngày k t> ngày xy ra tr=ng hp
11/19/2013 11:22 AM
p. 118
Bid 017-976001-GH
11/19/2013 11:22 AM
QUÝ V CÓ QUYN …
1. Hiu xem n xin và tr cp ca quý v ang c
x lý nh th nào.
2. c gii thích trc tip hoc bng vn bn v' n
xin và tr cp ca quý v.
3. Nhn c giy biên nhn m`i lJn np bt k[ tài liu
nào.
CÁC QUYN CA QUÝ V
Tt c m;i ng=i và tZ chc cung cp dch v? h` tr công
cng 'u phi tôn tr;ng các quy'n ca quý v. H; có th
giúp quý v hiu và np n xin các quy'n li và dch v?.
U
U
U
U
U
U
U
U
NU QUÝ V GP VN VI TR CP
HOC CÁC DCH V QUÝ V C HNG:
Gi h] s v' tt c các thông tin, tài liu và nhng
lJn quý v liên lc v
i qun.
Nhn c giy biên nhn m`i khi quý v np bt k[
th gì.
Quý v có th a ai ó i cùng mình t
i buZi gp v
i
cán s xã hi ph? trách h] s ca quý v.
Khiu ni. Có 4 cách thc hin:
Không chính quy: Quý v có th yêu cJu c nói
chuyn v
i mt nhân viên giám sát trình bày v'
các vn ' v
i mt cán s hoc xem li các quy
nh và quyt nh ' xut i v
i các khon tr cp
và dch v? ca quý v.
Phiên iu Trn Tiu Bang: Hi xin mt phiên i'u
trJn tiu bang nu có vn ' v
i các khon tr cp
hoc dch v? ca quý v. Quý v phi xin mt phiên
iu trn trong vòng 90 ngày k t khi qu
n ra
quyt nh. Quý v có th np n khiu ni sau 90
ngày nu có lý do chính áng, ví d? nh b bnh hoc
khuyt tt.
Khiu ni vì b phân bit i x: Nu quý v cho rng
qun ã phân bit i x v
i mình thì có th np n
khiu ni lên i'u Phi Viên v' Quy'n Dân S ca
Qun hoc C Quan Tiu Bang Ph? Trách v' Quy'n
Dân S, và cng có th np n lên Chính Ph Liên
Bang. Quý v phi np n trong vòng 180 ngày k
t> ngày b phân bit i x. bit thêm thông tin,
xin xem phJn có tên “Cm Phân Bit i X”.
Nu vic phân bit i x còn nh h@ng t
i các quy'n
li và dch v? ca quý v thì quý v cng phi xin mt
Xem h] s ca quý v.
Xem các lut và quy nh ca qun và tiu bang.
Yêu cJu mt th^m phán xem xét bt k[ quyt nh
nào ca qun v' tính hi i'u kin, các quy'n li
hoc dch v? c h@ng ca quý v.
7. Không b phân bit i x trong vic nhn các quy'n
li hay dch v? ca chng trình.
8. Np n khiu ni khi b phân bit i x.
9. c nhân viên ca qun tr giúp thêm m bo
rng quý v nhn c các quy'n li ca mình nu
quý v b mt tình trng khuyt tt hoc suy yu cn
tr@ vic thông hiu các i'u l ca chng trình.
10. c bo mt thông tin ca quý v.
11. c i x nhã nhn lch s và tôn tr;ng.
4.
5.
6.
CM PHÂN BIT I X
Theo lut Tiu Bang, các c quan tr cp xã hi không
c phép cp tr cp, các quy'n li hoc dch v? cho
quý v khác i so v
i các khon tr cp c cp cho
nhng ng=i khác vì lý do:
Chng Tc, Màu Da, Ngun Gc Quc Gia (bao
gm ngôn ng), Bn Sc Sc Tc, Tui, Tình Trng
Khuyt Tt, Tôn Giáo, Gii Tính, Xu Hng Tình
Dc, ng Phái Chính Tr, Tình Trng Hôn Nhân,
hoc Mi Quan H Bn Tình
Lut pháp liên bang cng nghiêm cm phân bit i x
da trên nhi'u (nhng không phi tt c) nhng i'u nêu
trên. Lut Liên Bang cng cm:
1. Trì hoãn hoc t> chi giao mt a tr làm con
nuôi hoc tm nuôi da trên chng tc, màu da,
ngu]n gc quc gia ca cha m nuôi hoc a tr
c nhn nuôi hoc tm nuôi;
2. T> chi không cho bt k[ mt cá nhân nào có c hi
c tr@ thành b/m nuôi hoc tm nuôi da trên
chng tc, màu da, ngu]n gc quc tch ca cá nhân
ó hay a tr có liên quan.
LÀM TH NÀO YÊU CU MT PHIÊN IU
TRN TIU BANG
1. Qua in thoi: Hi xin Phiên i'u TrJn Tiu Bang
bng cách liên lc v
i S@ Dch V? Xã Hi California
theo s (800) 743-8525 hoc (800) 952-5253
2. i'n thông tin vào mt sau ca Thông Báo Quyt
nh hoc gi n yêu cJu n:
744 P Street M.S. 09-17-37
C TIP TC NHN TR CP HOC
DCH V TRONG TH
I GIAN CH
PHIÊN
IU TRN
Qun phi gi thông báo cho quý v ít nht 10 ngày tr
c
khi thc hin bt k[ quyt nh nào thay Zi các khon tr
cp hoc dch v? ca quý v. Nu quý v xin mt phiên
i'u trJn tr
c khi quyt nh c thc hin thì quý v có
th c “h@ng tr cp trong khi ch=” phiên i'u trJn.
Nh vy có ngh~a là các khon tr cp ca quý v s+
không thay Zi gì cho n quý v nhn c quyt nh
ca phiên i'u trJn.
VÍ D V CÁC TR
NG HP B PHÂN BIT
I X
Qun không cung cp thông dch viên mi3n phí cho
quý v.
Mt cán s thông báo cho mt nhóm s\c tc nào ó
v' nhi'u chng trình và dch v? hn là cho ng=i
thuc nhóm s\c tc khác.
Quý v có tình trng khuyt tt khin cho khó ;c tài
liu vit nhng Qun không h` tr quý v có c
bng nghe h
ng dn chng trình.
Mt cán s xã hi thay Zi cách c x v
i quý v sau
khi bit v' tôn giáo hay quan im chính tr ca quý v.
Quý v PHI xin mt phiên iu trn nu không

Quý v không th t
i buZi hn vì tr? s@ qun không
!ng ý v"i b#t k$ thông báo m"i nào nh%n &'c.
có thang máy.
PHIÊN IU TRN TIU BANG
Quý v có th xin mt phiên i'u trJn tiu bang bt k[
lúc nào quý v không ]ng tình v
i mt quyt nh
ca qun v' các quy'n li hoc dch v? ca quý v.
Quý v cng có th xin mt phiên i'u trJn tiu bang
nu qun không cp cho quý v các quy'n li và dch
v? mà quý v cho rng mình áng c h@ng.
Các phiên i'u trJn tiu bang c mt Th^m Phán
Lut Hành Chính th? lý. Qun s+ có ng=i i din
ti phiên i'u trJn gii thích ti sao h; ã a ra
quyt nh ó.
Mt phiên i'u trJn tiu bang không phi là mt buZi
hJu tòa. Quý v có quy'n có i din cùng i v
i
mình. $ qun nào cng có các dch v? pháp lý mi3n
phí. Các dch v? này c lit kê @ mt sau ca các
t= thông báo ca qun. Quý v có th a nhân chng
n. Quý v có quy'n có thông dch viên mi3n phí.
Hãy hi qun bit cách xin thông dch viên.
x Nu vn ' ca quý v liên quan n chng
trình General Assistance hay tr cp chung thì
phi xin mt phiên i'u trJn @ qun.
x Nu vn ' ca quý v liên quan n các quy'n
li An Sinh Xã Hi, quý v phi liên lc v
i
Social Security Administration (C Quan An
Sinh Xã Hi).
phiên iu trn tiu bang nu mun phn i quyt nh
ca qun v' các quy'n li và dch v? ca mình.
Khiu ni: Quý v có th np n khiu ni lên qun
nu h; có th t?c khiu ni. Làm theo cách này
không bo v c các quyn li ca quý v nh
làm theo h
ng xin mt phiên i'u trJn tiu bang.
County of Orange
Bid 017-976001-GH
p. 119
County of Orange
Bid 017-976001-GH
Req # 1055789
3
Vietnamese
NACF PHONE-IN RRR
December 2013
Region
Quantity
ARC
1,000
AVRC
50
CRO
100
GGRC
1,825
SARC
375
TOTAL
3,350
2 STAPLES LEFT SIDE
11/19/2013 11:22 AM
p. 120
County of Orange
Bid 017-976001-GH
NOW, THEREFORE, the Parties mutually agree as follows:
General Terms and Conditions:
A.
B.
C.
D.
E.
F.
G.
H.
Governing Law and Venue: This Contract has been negotiated and executed in the state of California
and shall be governed by and construed under the laws of the state of California. In the event of any legal
action to enforce or interpret this Contract, the sole and exclusive venue shall be a court of competent
jurisdiction located in Orange County, California, and the Parties hereto agree to and do hereby submit to
the jurisdiction of such court, notwithstanding Code of Civil Procedure Section 394. Furthermore, the
Parties specifically agree to waive any and all rights to request that an action be transferred for trial to
another County.
Entire Contract: This Contract, including Attachments A, B, and Exhibit 1 (Blank Child Support
Enforcement Certification Requirements Form) which have been incorporated, when accepted by the
Contractor either in writing or by the shipment of any article or other commencement of performance
hereunder, contains the entire Contract between the Parties with respect to the matters herein and there are
no restrictions, promises, warranties or undertakings other than those set forth herein or referred to herein.
No exceptions, alternatives, substitutes or revisions are valid or binding on County unless authorized by
County in writing. Electronic acceptance of any additional terms, conditions or supplemental Contracts
by any County employee or agent, including but not limited to installers of equipment, shall not be valid
or binding on County unless accepted in writing by County’s Purchasing Agent or his designee,
hereinafter “Purchasing Agent”.
Amendments: No alteration or variation of the terms of this Contract shall be valid unless made in
writing and signed by the Parties; no oral understanding or agreement not incorporated herein shall be
binding on either of the Parties; and no exceptions, alternatives, substitutes or revisions are valid or
binding on County unless authorized by County in writing.
Taxes: Unless otherwise provided herein or by law, price quoted does not include California state sales or
use tax.
Delivery: Time of delivery of goods or services is of the essence in this Contract. County reserves the
right to refuse any goods or services and to cancel all or any part of the goods not conforming to
applicable specifications, drawings, samples or description, or services that do not conform to the
prescribed statement of work. Acceptance of any part of the order for goods shall not bind County to
accept future shipments, nor deprive it of the right to return goods already accepted, at Contractor’s
expense. Over shipments and under shipments of goods shall be only as agreed to in writing by County.
Delivery shall not be deemed to be complete until all goods, or services, have actually been received and
accepted in writing by County.
Acceptance/Payment: Unless otherwise agreed to in writing by County, 1) acceptance shall not be
deemed complete unless in writing and until all the goods/services have actually been received, inspected,
and tested to the satisfaction of County, and 2) payment shall be made according to the requirements
outlined in Attachment B, Compensation and Pricing Provisions.
Warranty: Contractor expressly warrants that the goods/services covered by this Contract are 1) free of
liens or encumbrances, 2) merchantable and good for the ordinary purposes for which they are used, and
3) fit for the particular purpose for which they are intended. Acceptance of this order shall constitute an
agreement upon Contractor’s part to indemnify, defend and hold County and its indemnities as identified
in paragraph “GG” harmless from liability, loss, damage and expense, including reasonable counsel fees,
incurred or sustained by County by reason of the failure of the goods/services to conform to such
warranties, faulty work performance, negligent or unlawful acts, and non-compliance with any applicable
state or federal codes, ordinances, orders, or statutes, including the Occupational Safety and Health Act
(OSHA) and the California Industrial Safety Act. Such remedies shall be in addition to any other
remedies provided by law.
Patent/Copyright Materials/Proprietary Infringement: Unless otherwise expressly provided in this
Contract, Contractor shall be solely responsible for clearing the right to use any patented or copyrighted
materials in the performance of this Contract. Contractor warrants that any Software as modified through
services provided hereunder will not infringe upon or violate any patent, proprietary right, or trade secret
right of any third party. Contractor agrees that, in accordance with the more specific requirement
contained in paragraph “GG” below, it shall indemnify, defend and hold County and County Indemnitees
GeneralTermsandConditions
11/19/2013 11:22 AM
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County of Orange
I.
Bid 017-976001-GH
harmless from any and all such claims and be responsible for payment of all costs, damages, penalties and
expenses related to or arising from such claim(s), including, but not limited to, attorney’s fees, costs and
expenses.
Assignment or Sub-contracting: The terms, covenants, and conditions contained herein shall apply to
and bind the heirs, successors, executors, administrators and assigns of the Parties. Furthermore, neither
the performance of this Contract nor any portion thereof may be assigned or sub-contracted by Contractor
without the express written consent of County. Any attempt by Contractor to assign or sub-contract the
performance or any portion thereof of this Contract without the express written consent of County shall be
invalid and shall constitute a breach of this Contract.
In the event that the Contractor is authorized by the County to subcontract, this Contract shall prevail and
the terms of the subcontract shall incorporate by reference and not conflict with the terms of this Contract.
In the manner in which the County expects to receive services, the County shall look to the Contractor for
performance and not deal directly with any subcontractor. All matters related to this Contract shall be
handled by the Contractor with the County; the County will have no direct contact with the subcontractor
in matters related to the performance of this Contract. All work must meet the approval of the County of
Orange.
J.
K.
L.
M.
N.
O.
P.
Non-Discrimination: In the performance of this Contract, Contractor agrees that it will comply with the
requirements of Section 1735 of the California Labor Code and not engage nor permit any subcontractors
to engage in discrimination in employment of persons because of the race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, marital status, or sex of such
persons. Contractor acknowledges that a violation of this provision shall subject Contractor to all the
penalties imposed for a violation of anti-discrimination law or regulation, including but not limited to,
Section 1720 et seq. of the California Labor Code.
Termination: In addition to any other remedies or rights it may have by law, County has the right to
terminate this Contract without penalty immediately with cause or after 30 days’ written notice without
cause, unless otherwise specified.
Cause shall be defined as any breach of Contract, any
misrepresentation or fraud on the part of the Contractor. Exercise by County of its right to terminate the
Contract shall relieve County of all further obligation. If the Contract is terminated for any reason,
County shall be entitled to an immediate refund of 1/12th of Contract amount multiplied by the number of
months remaining in the paid annual maintenance/support period.
Consent to Breach Not Waiver: No term or provision of this Contract shall be deemed waived and no
breach excused, unless such waiver or consent shall be in writing and signed by the Party claimed to have
waived or consented. Any consent by any Party to, or waiver of, a breach by the other, whether express
or implied, shall not constitute consent to, waiver of, or excuse for any other different or subsequent
breach.
Remedies Not Exclusive: The remedies for breach set forth in this Contract are cumulative as to one
another and as to any other provided by law, rather than exclusive; and the expression of certain remedies
in this Contract does not preclude resort by either Party to any other remedies provided by law.
Independent Contractor: Contractor shall be considered an independent Contractor and neither
Contractor, its employees nor anyone working under Contractor shall be considered an agent or an
employee of County. Neither Contractor, its employees nor anyone working under Contractor, shall
qualify for workers’ compensation or other fringe benefits of any kind through County.
Performance: Contractor shall perform all work under this Contract, taking necessary steps and
precautions to perform the work to County’s satisfaction. Contractor shall be responsible for the
professional quality, technical assurance, timely completion, and coordination of all documentation and
other goods/services furnished by the Contractor under this Contract. Contractor shall perform all work
diligently, carefully, and in a good and workman-like manner; shall furnish all labor, supervision,
machinery, equipment, materials, and supplies necessary therefore; shall at its sole expense obtain and
maintain all permits and licenses required by public authorities, including those of County required in its
governmental capacity, in connection with performance of the work; and, if permitted to subcontract,
shall be fully responsible for all work performed by subcontractors.
Bills and Liens: Contractor shall pay promptly all indebtedness for labor, materials, and equipment used
in performance of the work. Contractor shall not permit any lien or charge to attach to the work or the
premises, but if any does so attach, Contractor shall promptly procure its release and, in accordance with
11/19/2013 11:22 AM
ʹ
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County of Orange
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Z.
AA.
BB.
CC.
DD.
Bid 017-976001-GH
the requirements of paragraph “GG” below, indemnify, defend, and hold County harmless and be
responsible for payment of all costs, damages, penalties and expenses related to or arising from or related
thereto.
Changes: Contractor shall make no changes in the work or perform any additional work without the
County’s specific written approval.
Change of Ownership: Contractor agrees that if there is a change or transfer in ownership of
Contractor’s business prior to completion of this Contract, the new owners shall be required under terms
of sale or other transfer to assume Contractor’s duties and obligations contained in this Contract and
complete them to the satisfaction of County.
Force Majeure: Contractor shall not be assessed with liquidated damages or unsatisfactory performance
penalties during any delay beyond the time named for the performance of this Contract caused by any act
of God, war, civil disorder, employment strike or other cause beyond its reasonable control, provided
Contractor gives written notice of the cause of the delay to County within 36 hours of the start of the
delay and Contractor avails himself of any available remedies.
Confidentiality: Contractor agrees to maintain the confidentiality of all County and County-related
records and information pursuant to all statutory laws relating to privacy and confidentiality that currently
exist or exist at any time during the term of this Contract. All such records and information shall be
considered confidential and kept confidential by Contractor and Contractor’s staff, agents and employees.
Compliance with Laws: Contractor represents and warrants that services to be provided under this
Contract shall fully comply, at Contractor’s expense, with all standards, laws, statutes, restrictions,
ordinances, requirements, and regulations (collectively “laws”), including, but not limited to those issued
by County in its governmental capacity and all other laws applicable to the services at the time services
are provided to and accepted by County. Contractor acknowledges that County is relying on Contractor to
ensure such compliance, and pursuant to the requirements of paragraph “GG” below, Contractor agrees
that it shall defend, indemnify and hold County and County Indemnitees harmless from all liability,
damages, costs, and expenses arising from or related to a violation of such laws.
Freight (F.O.B. Destination): Contractor assumes full responsibility for all transportation, transportation
scheduling, packing, handling, insurance, and other services associated with delivery of all products
deemed necessary under this Contract.
Pricing: The Contract price shall include full compensation for providing all required goods in
accordance with required specifications, or services as specified herein or when applicable, in the Scope
of Work attached to this Contract, and no additional compensation will be allowed therefore, unless
otherwise provided for in this Contract.
Waiver of Jury Trial: Each Party acknowledges that it is aware of and has had the opportunity to seek
advise of counsel of its choice with respect to its rights to trial by jury, and each Party, for itself and its
successors, creditors, and assigns, does hereby expressly and knowingly waive and release all such rights
to trial by jury in any action, proceeding or counterclaim brought by any Party hereto against the other
(and/or against its officers, directors, employees, agents, or subsidiary or affiliated entities) on or with
regard to any matters whatsoever arising out of or in any way connected with this Contract and /or any
other claim of injury or damage.
Terms and Conditions: Contractor acknowledges that it has read and agrees to all terms and conditions
included in this Contract.
Headings: The various headings and numbers herein, the grouping of provisions of this Contract into
separate clauses and paragraphs, and the organization hereof are for the purpose of convenience only and
shall not limit or otherwise affect the meaning hereof.
Severability: If any term, covenant, condition, or provision of this Contract is held by a court of
competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions hereof shall
remain in full force and effect and shall in no way be affected, impaired or invalidated thereby.
Calendar Days: Any reference to the word "day" or "days" herein shall mean calendar day or calendar
days, respectively, unless otherwise expressly provided.
Attorney Fees: In any action or proceeding to enforce or interpret any provisions of this Contract, or
where any provisions hereof is validly asserted as a defense, each Party shall bear its own attorney’s fees,
costs and expenses.
Interpretation: This Contract has been negotiated at arm’s length and between persons sophisticated and
knowledgeable in the matters dealt with in this Contract. In addition, each Party has been represented by
11/19/2013 11:22 AM
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County of Orange
EE.
FF.
GG.
Bid 017-976001-GH
experienced and knowledgeable independent legal counsel of their own choosing or has knowingly
declined to seek such counsel despite being encouraged and given the opportunity to do so. Each Party
further acknowledges that they have not been influenced to any extent whatsoever in executing this
Contract by any other Party hereto or by any person representing them, or both. Accordingly, any rule or
law (including California Civil Code Section 1654) or legal decision that would require interpretation of
any ambiguities in this Contract against the Party that has drafted it is not applicable and is waived. The
provisions of this Contract shall be interpreted in a reasonable manner to affect the purpose of the Parties
and this Contract.
Authority: The Parties to this Contract represent and warrant that this Contract has been duly authorized
and executed and constitutes the legally binding obligation of their respective organization or entity,
enforceable in accordance with its terms.
Employee Eligibility Verification: The Contractor warrants that it fully complies with all Federal and
State statutes and regulations regarding the employment of aliens and others and that all its employees
performing work under this Contract meet the citizenship or alien status requirement set forth in Federal
statues and regulations. The Contractor shall obtain, from all employees performing work hereunder, all
verification and other documentation of employment eligibility status required by Federal or State statutes
and regulations including, but not limited to, the Immigration Reform and Control Act of 1986, 8 U.S.C.
§1324 et seq., as they currently exist and as they may be hereafter amended. The Contractor shall retain
all such documentation for all covered employees for the period prescribed by the law. The Contractor
shall indemnify, defend with counsel approved in writing by County, and hold harmless, the County, its
agents, officers, and employees from employer sanctions and any other liability which may be assessed
against the Contractor or the County or both in connection with any alleged violation of any Federal or
State statutes or regulations pertaining to the eligibility for employment of any persons performing work
under this Contract.
Indemnification Provisions: Contractor agrees to indemnify, defend with counsel approved in writing
by County, and hold County, its elected and appointed officials, officers, employees, agents and those
special districts and agencies which County’s Board of Supervisors acts as the governing Board (“County
Indemnitees”), harmless from any claims, demands or liability of any kind or nature, including but not
limited to personal injury or property damage, arising from or related to the services, products or other
performance provided by Contractor pursuant to this Contract. If judgment is entered against Contractor
and County by a court of competent jurisdiction because of the concurrent active negligence of County or
County Indemnitees, Contractor and County agree that liability will be apportioned as determined by the
court. Neither Party shall request a jury apportionment.
11/19/2013 11:22 AM
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p. 124
County of Orange
Bid 017-976001-GH
Question and Answers for Bid #017-976001-GH - Social Services Agency Food
Stamp Recertification Packets
OVERALL BID QUESTIONS
Question 1
The CF 285 R9-13 section of 16 pages, do these get printed 1/1 for a total of 8 sheets printed front and back? Also, must
these be stapled in the right top corner? (Submitted: Nov 19, 2013 8:34:02 AM PST)
Answer
- CF 285 R9-13 is 8 physical pieces of paper, printed 2 sided which totals 16 pages. This staples top left corner. (Answered: Nov
19, 2013 9:25:28 AM PST)
Question 2
Informing Notices section of 12 pages, must these be printed as single sided prints or double sided prints - 1/1? Must this
section be stapled in the right top corner? Page 4 and Page 8 are blank in this section are these blank pages correct?
(Submitted: Nov 19, 2013 8:37:29 AM PST)
Answer
- Informing Notices varies by language, En-12 Pages, Sp-14, Vn-14. They all print 2 sided, the blanks pages are included as the
back side for pages with no printing on back. This staples top Left Corner. (Answered: Nov 19, 2013 9:25:28 AM PST)
Question 3
The shipping instructions page for each group of packets indicates that a staple be placed on the top and bottom of the left
hand side of the page. Do the packets have to be compiled together and then to complete each packet they need to be stapled
twice on the left hand side? (Submitted: Nov 19, 2013 8:42:13 AM PST)
Answer
- All subsections are collated together and 2 staples on Left side. (Answered: Nov 19, 2013 9:25:28 AM PST)
Question 4
On the PS Requisitions on this bid it does not state the paper weight is 20# white bond acceptable? And is it printed 1-color
black? (Submitted: Nov 19, 2013 10:06:24 AM PST)
Answer
- 20# is correct and 1 color Black Ink. (Answered: Nov 19, 2013 10:19:43 AM PST)
Question 5
On the PS Requisitions it under Bindery - Collating is marked as NO, does the county require these packets to be collated,
stapled and assembled as complete packets and then stapled again? (Submitted: Nov 19, 2013 10:07:55 AM PST)
Answer
- Each subsection is created, then all subsections are collated and receive 2 Staples on Left Side to create a Packet. (Answered:
Nov 19, 2013 10:19:43 AM PST)
Question Deadline: Nov 19, 2013 12:00:00 PM PST
11/19/2013 11:22 AM
p. 125

Social Services Agency Food Stamp Recertification

Transcripción

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