CalFresh Student Pre-Screening Form

Name of Campus *

California State University, Los Angeles

Student Name (First + Last) *

CIN *

Phone *

Email *

Age *

"Mandatory Household" - Does one of the following living situations describe you?: *

If you are a part of a "Mandatory Household" (see checkbox options), then you must apply together with the other adult members of your household (Cal State LA CalFresh staff can help with that).

Married couple living together

Under the age of 22 and living with biological, adoptive, or stepparent(s)

Unmarried couple living together with common child

None of the above apply

Household Size: How many people do you purchase and prepare food with? *

The amount of CalFresh benefits one is eligible for is determined in part by the size on one's household. Household = an individual, couple, or family that purchases and prepares food together

Not applicable, I live in a Mandatory Household (see question above)

Household size = 1 (I purchase and prepare food for myself)

Household size = 2 (purchase and prepare food with one other, example: roommate)

Household size = 3 (purchase and prepare food with two others)

Houselhold size = 4 (purchase and prepare food with three others)

Household size = 5 (purchase and prepare food with four others)

Is your Household Income BELOW the following monthly limits?: •Household size of 1 - $2,148 •Household size of 2 - $2,904. •Household size of 3 - $3,660. •Household size of 4 - $4,418. •Household size of 5 - $5,174 *

SEE previous question for number of people in your household.

YES

NO

Does your household include at least one US citizen, a person with a Green Card, or lawful permanent resident (LPR)? *

YES

NO

Remember this applies to you if you are a household of one.

Is anyone in household provided more than half (11 or more) meals per week from another source (like a campus meal plan)? *

YES

NO

If yes, household members with a secured food source will not be eligible for CalFresh food benefits.

Is anyone in household physically/mentally unable to work and/or is receiving disability benefits from any source? *

YES

NO

Would rather not answer

Are you enrolled this semester at least half time - 6 units or more undergraduate student, 4 units or more graduate student? *

YES

NO

Which county do you reside in? (E.g. Los Angeles, Orange) *

Do you live on campus? *

Yes

No

If no, do you live with parents? *

Yes

No

Check ALL that apply: *

Referral Program - Did a Cal State LA Student refer you to apply with us? If so, please type their name.

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Office of the Dean of Students

CalFresh Student Pre-Screening Form