TANF Application

Important Form Information:

Directions for application.

To download the checklist of required documents to submit with the application, click here.

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Section 1: Head of Household Name

Last Name(Required)

First Name(Required)

Middle Name

Date of Birth(Required)

Gender(Required)

Male

Female

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Primary Phone #(Required)

Please list 999-999-9999 if you do not have an phone. It is required to submit online applications.

Email(Required)

Please call XXX-XXX-XXX, if you do not have an email address. We will help you set up an email address. It is required to submit online applications.

Ethnicity(Required)

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Social Security #(Required)

Driver's License or CA Issued ID #

Please indicate your tribal affiliation:

Member of Federally Recognized Tribe:

Enrollment #

US Citizen(Required)

Yes

Is there an absent parent?(Required)

Yes

Have you ever received TANF/CalWORKs before?(Required)

Yes

List Prior TANF Information

Where

Number of Months

Have you ever lived in another County, City, or State?(Required)

Yes

List Other Living Information

Where

When

Marital Status(Required)

Maiden Name

How are you related to the children in this application?(Required)

Custodial Mother

Custodial Father

Caretaker/Guardian

Other

List Other Relationship

Education Level(Required)

9th Grade

10th Grade

11th Grade

HS Diploma

GED/CHSPE

College

Technical/Vocational School

Other

List Other Education Level

Are you currently employed?(Required)

Yes

List Current Employer Information

Name of Employer

Hours per Week

Gross Monthly Income

Are you currently enrolled and attending school/vocational training?(Required)

Yes

List School Information

Name of School

Hours per Week

Section 2: Co-Applicant Information

Would you like to add a Co-Applicant?(Required)

Yes

Hidden

Section 2: Co-Applicant Information

Last Name

First Name

Middle Name

Date of Birth(Required)

Gender(Required)

Male

Female

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Primary Phone #(Required)

Please list 999-999-9999 if you do not have an phone. It is required to submit online applications.

Email(Required)

Please call 999-999-9999, if you do not have an email address. We will help you set up an email address. It is required to submit online applications.

Ethnicity(Required)

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Social Security #(Required)

Driver's License or CA Issued ID #

Please indicate your Federally Recognized Tribal Affiliation:

Enrollment #

US Citizen(Required)

Yes

Pregnant?(Required)

Yes

Prior TANF Client(Required)

Yes

List Prior TANF Information

Where

Number of Months

Have you ever lived in another County, City, or State?(Required)

Yes

List Other Living Information

Where

When

Marital Status(Required)

Maiden Name

How are you related to the children in this application?(Required)

Custodial Mother

Custodial Father

Caretaker/Guardian

Other

List Other Relationship

Education Level(Required)

9th Grade

10th Grade

11th Grade

HS Diploma

GED/CHSPE

College

Technical/Vocational School

Other

List Other Education Level

Are you currently employed?(Required)

Yes

List Current Employer Information

Name of Employer

Hours per Week

Gross Monthly Income

Are you currently enrolled and attending school/vocational training?(Required)

Yes

List School Information

Name of School

Hours per Week

Section 3: Household Composition

The following documentation must be provided for EACH qualifying applicant: (Birth Certificate, Social Security Card, Tribal Verification, Proof of income, Immunization records, School enrollment, and Attendance verification)

Child 1

Last Name(Required)

First Name(Required)

Middle Name

Relationship to Applicant

Daughter or Son

Relative

Other

List Other Relationship

Social Security #(Required)

Date of Birth(Required)

Age

Gender(Required)

Male

Female

Ethnicity(Required)

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Tribal Affiliation(Required)

Is this Child an Enrolled Member of a Federally Recognized Tribe?(Required)

Yes

Enrollment #

US Citizen(Required)

Yes

Is this Child receiving SSI Benefits?

Yes

Is this Child blind, deaf, or disabled?(Required)

Yes

If yes, please explain child disability:

Is this Child currently enrolled in school?(Required)

Yes

List School Information

Name of School

Grade

Was this Child born out of wedlock?(Required)

Yes

Does this Child own a Bank or Trust Account?(Required)

Yes

Do you receive Child Support for this child?(Required)

Yes

Amount Received

Is this Child Support court ordered?

Yes

Would you like to add additional children?(Required)

Yes

Child 2

Last Name

First Name

Middle Name

Relationship to Applicant

Daughter or Son

Relative

Other

List Other Relationship

Social Security #

Date of Birth

Age

Gender

Male

Female

Ethnicity

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Tribal Affiliation

Is this Child an Enrolled Member of a Federally Recognized Tribe?

Yes

Enrollment #

US Citizen

Yes

Is this Child receiving SSI Benefits?

Yes

Is this Child blind, deaf, or disabled?

Yes

If yes, please explain child disability:

Is this Child currently enrolled in school?

Yes

List School Information

Name of School

Grade

Was this Child born out of wedlock?

Yes

Does this Child own a Bank or Trust Account?

Yes

Do you receive Child Support for this child?

Yes

Amount Received

Is this Child Support court ordered?

Yes

Would you like to add additional children?

Yes

Child 3

Last Name(Required)

First Name(Required)

Middle Name

Relationship to Applicant(Required)

Daughter or Son

Relative

Other

List Other Relationship

Social Security #

Date of Birth(Required)

Age

Gender(Required)

Male

Female

Ethnicity(Required)

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Tribal Affiliation(Required)

Is this Child an Enrolled Member of a Federally Recognized Tribe?(Required)

Yes

Enrollment #

US Citizen

Yes

Is this Child receiving SSI Benefits?(Required)

Yes

Is this Child blind, deaf, or disabled?(Required)

Yes

If yes, please explain child disability:

Is this Child currently enrolled in school?(Required)

Yes

List School Information

Name of School

Grade

Was this Child born out of wedlock?(Required)

Yes

Does this Child own a Bank or Trust Account?(Required)

Yes

Do you receive Child Support for this child?

Yes

Amount Received

Is this Child Support court ordered?

Yes

Would you like to add additional children?

Yes

Child 4

Last Name

First Name

Middle Name

Relationship to Applicant

Daughter or Son

Relative

Other

List Other Relationship

Social Security #

Date of Birth

Age

Gender

Male

Female

Ethnicity

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Tribal Affiliation

Is this Child an Enrolled Member of a Federally Recognized Tribe?

Yes

Enrollment #

US Citizen

Yes

Is this Child receiving SSI Benefits?

Yes

Is this Child blind, deaf, or disabled?

Yes

If yes, please explain child disability:

Is this Child currently enrolled in school?

Yes

List School Information

Name of School

Grade

Was this Child born out of wedlock?

Yes

Does this Child own a Bank or Trust Account?

Yes

Do you receive Child Support for this child?

Yes

Amount Received

Is this Child Support court ordered?

Yes

Would you like to add additional children?

Yes

Child 5

Last Name

First Name

Middle Name

Relationship to Applicant

Daughter or Son

Relative

Other

List Other Relationship

Social Security #

Date of Birth

Age

Gender

Male

Female

Ethnicity

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Tribal Affiliation

Is this Child an Enrolled Member of a Federally Recognized Tribe?

Yes

Enrollment #

US Citizen

Yes

Is this Child receiving SSI Benefits?

Yes

Is this Child blind, deaf, or disabled?

Yes

If yes, please explain child disability:

Is this Child currently enrolled in school?

Yes

List School Information

Name of School

Grade

Was this Child born out of wedlock?

Yes

Does this Child own a Bank or Trust Account?

Yes

Do you receive Child Support for this child?

Yes

Amount Received

Is this Child Support court ordered?

Yes

Others Living in the Home

Other adult/children living in the home NOT applying for TANF

List Others Living in the Home

Name (First Middle, Last)

Relationship to Applicant

Age

Gender

Do any of these situations apply to you or your family?

Check ALL that apply.

Medical Emergency

Eviction notice

Homeless

Domestic Violence

Utility Shutoff Notice

Pregnancy

Disability

Past due accounts

None of the above

Explain Past Due Account

Disability Type

Pregnant, List Due Date

Do you currently receive Housing Assistance?(Required)

Yes

If Yes, which Program?

Public Housing

Rental Assistance

Tribal Housing Assistance

Other

List Other Program(s)

Section 4: Income/Benefits Verification

Have you or any member of the household applying for TANF received any type of income in the past three (3) months?

Check ALL that Apply.

List Income & Benefits

Type of income/benefit

Recipient

Amount Received (before deductions)

How often (weekly, Bi-weekly, monthly)

Do you rent or own your home?

Rent

Own

Are you receiving assistance from any other federal state or county agencies for rent?(Required)

Yes

If Yes, explain:

Are you receiving assistance from any other federal, state, or county agencies for utilities?(Required)

Yes

If Yes, explain:

Section 5: Assets & Resources

Do you own a Savings or Checking Account?(Required)

Yes

List Account Information

Type (Savings, Checking)

Account Holder

Bank Name

Current Balance

Does anyone applying for TANF Assistance OWN any of the following?

Homes

Business properties

Personal properties

Bonds, Stocks, Trusts

List Property Information

Asset/Resource Type

Address (if property)

Asset Owner

Current Value

Amount Owed

Do you or anyone applying for TANF Services own or make payments for any vehicles, Including cars, trucks, motorcycles, trailers, boats, snowmobiles, or any other type of vehicle(Required)

Yes

List Vehicle Information

Vehicle Type

Registered Owner

Year

Vehicle Condition

Approx. Amount of miles on vehicle

Owned

Car Payment Amount

Section 6: Other Eligibility Questions

Have you or any member of your household been convicted of fraudulently receiving duplicate Food Stamps (Cal FRESH), TANF, Medi-Cal(Medicaid) or SSI benefits in any state?(Required)

Yes

If yes, when:

Are you or any member of your household hiding or running from law enforcement to avoid prosecution, being taken into custody, or going to jail for a felony, attempted felony, or violating a condition of parole?(Required)

Yes

Have you or any member of your household been convicted of a felony under Federal or State law for the possession, use or distribution of a controlled drug substance (Felony drug conviction) or for a crime committed while under the influence of a controlled drug substance?(Required)

Yes

If yes, when:

Have you or any member of your family convicted of a felony drug charge completed a Drug Rehabilitation program?(Required)

Yes

If yes, when:

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