Please answer the following questions to see if you may be eligible for CalFresh benefits. Once you submit your form a CalFresh Outreach team member will reach out to you via email and/or text to discuss eligibility. COC Student Email Address Full Name Phone Number In order to determine the number of people on an application we must review the number of people in your household. Household = a person living alone or a group of people living together who purchase and prepare food together. Effective September 30, 2021 Number of People in Household Gross Monthly Income Limit CalFresh Food Allotment Range 1 $2,148 $250 2 $2,904 $459 3 $3,660 $658 4 $4,418 $835 5 $5,174 $992 6 $5,930 $1,190 7 $6,688 $1,316 8 $7,444 $1,504 Each Additional Member +$758 +$188 NOTE: when answering the following questions, feel free to select Not Sure and a BaNC representative can reach out to assist. 1. How many people do you purchase and prepare food with? 1 2 3 4 5 More than 5 2. Using both the chart above and your answer from question 1, is your household under the gross monthly income? Yes No Not Sure 3. Does your household include at least one US citizen, a person with a Green Card, or lawful permanent resident (LPR)? Yes No Not Sure 4. Does anyone in your household receive the Food Distribution Program on Indian Reservations (FDPIR) ? Yes No Not Sure 5. Is anyone in your household physically/mentally unable to work and/or is receiving disability benefits from any source? Yes No Not Sure 6. Is anyone in your household a college student per CalFresh Food guidelines: enrolled at least half-time (6 units) AND between ages of 18-49? Yes No Not Sure 7. Students Must Meet at Least ONE; please mark all that apply. Not a student per CalFresh TEMPORARY COVID STUDENT EXEMPTIONS—until the public health emergency has been lifted—see bit.ly/ACL-21-11 $0 Expected Family Contribution (EFC) as defined by CSAC or on Student Aid Report Eligible for state or federal work study as determined by the Financial Aid office on each campus Working and getting paid for at least 20 hours per week Approved (or awarded or accepted) for federal or state work study Receiving Cal Grant A OR B Enrolled in a state funded program that increases employability (EOPS, WIOA, DSPS, CARE, McNair, or MESA) Enrolled in a program that increases employability for current and former foster youth (Guardian Scholars, FYSI, CAFYES, ETV, RISE, or Extended Foster Care) Participating in the CalFresh Employment and Training Program (CFET) or Job Opportunities and Basic Skills (JOBS), or be a recipient of CalWORKs or Aid to Families with Dependent Children (AFDC) Exerting parental control over a dependent household member under the age of 6 OR between the age of 6 and 12 with no adequate childcare* OR are a single parent of a dependent household member under the age of 12 *As determined by the county on a case-by-case basis I am a student per CalFresh but do not meet any of the above statements Not a student per CalFresh (enrolled halftime and between ages 18-49) Leave this field blank