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 October 1, 2024 Number of People in Household Gross Monthly Income Limit CalFresh Food Allotment Range 1 $2,510 $250 2 $3,408 $459 3 $4,304 $658 4 $5,200 $835 5 $6,098 $992 6 $6,994 $1,190 7 $7,890 $1,316 8 $8,788 $1,504 Each Additional Member +$898 +$188 NOTE: when answering the following questions, feel free to select Not Sure and a BaNC representative can reach out to assist. 1. Including yourself, how many people do you purchase and prepare food with? (If you're under 22 you must include parents if you live with them) Household: A household is a group of people that live together and regularly buy and prepare food together. I buy and make most of my meals alone. 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 lawful permanent resident? Yes No Not Sure 4. How old are you? 5. Are you a college student enrolled half-time or more? (6 units min) 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. On average, I work at least 20 hours per week Approved for federal or state work study Receiving Cal Grant A OR B Enrolled in a local program to increase employability I have a chiled 12 or younger I am a student per CalFresh but do not meet any of the above statements Not a student per CalFresh Leave this field blank