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C4Yourself External User Guide

1. First Name Seymour Last Name ourself Document Invalid file formet Only PDF or TUE file types can 10 If it is the correct document click My Messages My gt Do d Ay Appications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Status Due Date Mail in Cover Sheet vercation Renan ust ere Om 1072032 ch Status Reports Status Due Date SMSP Rights and tery Sar vanade 06 06 2032 R ibibiti CMS 219 Statement of Facts Status Due Date Riek e asibiliti You currently have no statement of facts documents SAWS 2A Upload My Documents Register to Vote C Yoursel User Gude Bre oo Remove Select Document To view forms you must have Adobe Reader 11 Document name under Upload My Documents will change to You currently have no documents pending upload Version 12 09 May 8 2013 C4YourselfExternal User Guide TE dack ees ml Call Me Live Chat Home Help CHY OUYSELT Ke npt Loes Cambiar idioma My Things To Do My Benefits My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Due Date Mail in Cover Sheet Wense IECH Fax Cove
2. Version 12 09 May 8 2013 C4YourselfExternal User Guide aa The Am I Eligible page appears with a response The response may be an estimate of what you may get or it may say that we can t determine if you are eligible without more details Either way you are encouraged to continue the application process Home Help C4 AY ourself Access to Benefits Simplified Cambiar idioma Am I Eligible Based on your answers you may get as much as 526 00 from the CalFresh Program Alpine Amador Butte Calaveras Colusa Del Norte El Dorado Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Plumas Riverside San Benito San Bernardino San Joaquin Shasta Sierra Siskiyou Stanislaus Sutter Tehama Trinity Tuolumne and Yuba Counties in California allow you to submit a CalFresh application online For other counties you can print a blank application form from the Food And Nutrition Information Page You can then turn your application in at your nearest social services office or Home Help CAyYourself Access to Benefits Simplified Am I Eligible Based on what you told us we can not determine if you are eligible without more details Please complete the application which will give us the information we need to make an eligibility determination Alpine Amador Butte Calaveras Colusa Del Norte El Dorado Glenn
3. Iniciar una solicitud Asistencia Monetaria Alimentos Nutricion Medico Mi C4Yourself Si ha creado anteriormente una cuenta de CFrourself usted puede tener acceso a ella oprimiendo las conexiones abajo Acceso a Beneficios Simplificado Crear una Cuenta Revisar Mensajes Ver Formas Revisar Beneficios CA4Yourself es un sistema de uso por Internet Ver Cosas que Hacer Abrir Solicitudes Guardadas que le permite solicitar para beneficios Este es un sitio asegurado y toda su informacion sera privada y segura Ss Vea su saldo de EBT condados de C4Yourself en California Vea un mapa y lista de todos los condados de c4Yourself 2 Comuniquese con el condado sobre su caso existente Anuncios Mer informaci n sobre su caso s existente s a traws de su cuenta de C4yYourself Oprima aqui para iniciar la sesi n ua 401 C4yYourself es una marca registrada de la Autoridad de Poderes Conjuntos del Consorcio IV de California a nivel estatal del Sistema Automatizado de Bienestar SAWS If you would like any language other than English or Spanish choose the language from the Language selection drop down by clicking the small arrow at the right click on the language you want and the blue Cambiar idioma button CAY ourselt ess to Benefits Simplified zl Apply fo Start an apr WY Cash Assistan Medical mg ae Gan 3 1 My C4You If you have al log in by following the links b
4. Start P _ Application People Income Expenses Housing Costs Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Type How Much How Often Rent 125 00 Monthly House mortgage payment 850 00 Monthly Property Taxes if not in house payment 500 00 Annually Edit Insurance if not in house payment 200 00 Quarterly Seymour Yourself Does anyone else in the home pay housing costs Yes No TT 3 Review the information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Housing Costs page with the information you entered so you can change it Clicking takes you back to an empty Housing Costs page so you can start over with this page 4 lf you have more housing cost information to add click Yes J and repeat the process for each person in your household who pays housing costs 5 Click co or Next if the information is complete The Utility Costs page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide Utility Costs The Utility Costs pages gathers information about your utility expenses including Gas Electricity Water Telephone heating or cooking fuels such as propane or wood sewage garbage and trash installation of utilities etc In our sample case we ll say that Seymour pays
5. Administrative Service 90415515 Phone 909 388 0245 Fax 209 667 0002 Worker Name Sam Sharp Worker ID 364S011270 Wierker Phone Nrmher ANQ 4734431 Fyt AAR nur local office Version 12 09 May 8 2013 C4YourselfExternal User Guide 23 Click 2059 The window will close 24 The My Forms page now has a Sign button under the Status 25 Click ED the Electronic Signature page appears Use the same eSign User Name and eSign PIN you used when you submitted your e Application 26 Select your Name from the Name drop down If you do not see your name in this drop down you will need to create a eSign User Name and PIN 27 Enter your eSign User Name and eSign PIN 28 Click MES I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained in this statement of facts is true correct and complete Name Seymour Yourself 04 29 1972 Le eSign Username Seymour01 eSign PIN eeeee Description Signature Name Select One eSign Username eSign PIN Description Signature of spouse domestic partner or other parent of cash aided children Name Select One eSign Username eSign PIN Description Signature of Witness to Mark Interpreter or Person Acting for Applicant Beneficiary Please select your name and enter your eSign Username and eSign PIN Click the Sign button to send your application 29 The Status o
6. CA yourself Access to Benefits Simplified External Users Guide Version 12 09 Version 12 09 May 8 2013 Blank Page Version 12 09 May 8 2013 Revision History DATE PAGE S REVISION AUTHOR 11 26 2012 Initial Version 12 09 Version 12 09 May 8 2013 Blank Page Version 12 09 May 8 2013 Table of Contents Terms and Kl UL E 1 Public Assistance e el E 6 About the C4Yourself on line e Application cccccccseececeececeeeeeceeeesseeeeseeeessueeeseesesseeesseeesaaees 14 Do need to have a Computer cc ceecccceececeeeeeceeeeceeceseeeeeseuceseeeeeseueesseeesseeeeseeesseeeseeeesseeeeas 14 C4Yourself Kiosk Locations 15 C4Yourself Mobile Application cccccecccceececeeeeeceeeeeeeeeeseeceseueeeseeeeseueesseeeeseeesseeeesaeeessaeeesaes 16 The Applicaton OCC EE 16 Checklist of things you will need tO provide cccecccceeeeceeeeeceeceteeeeeceeeeseeeeeseeeesseeeeseeeesaeeeas 17 PDO UE Eeer ee ee ee 19 Sample Case INMOLMAUNON EE 19 Oe aa i a i e O E E T 19 Tips for Using Cay ourself EE 20 Bars LINKS Buttons and more 20 TMG FIC ACN EE 20 Language Se lSCUOM ME 20 Cheese E de BT LE 23 Te eeler E 23 BleiaK E 23 Brell e MOM ANION BE 24 Selen 24 Eiter 24 VON LO O reene ater staeciaatcunscacsnas at eesssenierstageinetcacateenessdeesaseaiteseacnesesansinemescicessues 25 Entennd dolar NNO ai 26 OG VOUNSEIE TIONG DAO nisnin EEE ERE E EEE E EE E EEEE 27 Version 12 09
7. Net If the answers are not correct a message appears Version 12 09 May 8 2013 C4Yourself External User Guide Home Help Secret Questions Your answers did not match our records User Name Seymour Yourself Secret question What is your favorite pastime Your answer Please enter your answer to your first secret question ZAE Sean Which phone number do you remember most from your childhood Your answer Please enter your answer to your second secret question Click the Next button to check your answers against our records Next 4 Click Back J The Login page appears 5 Click register a new account here link text on the Login page 6 Enter the required information on the Create User Account page and clic Mear The My Applications page appears If you had started an application but not finished it you will need to start again Version 12 09 May 8 2013 C4YourselfExternal User Guide gg Call Me amp Live Chat C4Yourself has a function that allows you to ask a Case Manager to call you or to chat live with a Case Manager You will not see the links to these functions until you register an account with a C IV county that supports these functions Currently the Call Me and Live Chat also known as Click to Chat functions are only available some C IV Counties Call Me and Live Chat Availability COUNTY CAL ee ME CHAT San Bernardino v y 7 30 am 5 30 pm PST Monday to F
8. Register to Wote Select Document To view forms you must hawe Adobe Reader 9 You should check to make sure you got the right document If you picked a document that is not a PDF or TIFF file you will get an error message like the one below Click and repeat the process Version 12 09 May 8 2013 C4Yourself External User Guide Home Moy ot Yourself Help CF Y OLLIE Se L f Ei TN to Benefits S rmplitieed Please provide information so that we can link your document to the appropriate case Mote use of this site is limited solely to legitimate C4yYourself purposes and any documents or files Submitted electronically will become part of the user s case file Submission of any inappropriate material is stricthy prohibited Inappropriate material includes but is not limited to the following wiruses or malicious code content that if commercial pornographic contains nudity threatening wiohent discriminatory or unlawful copyrighted material used without permission of the owner content or code which attempts to gather the personal information of other users phishing Submission of unlawful material will be referred to the appropriate authorities Document Information Send Docu Your form contains errors e Document Inwalid file format Only PDF or TIF file types can be uploaded Link Document Teo E App Number cnv 12 275 008 497 Document Typer Other File gt
9. San Bernardino 15010 Palmdale Road Victorville CA San Bernardino 2050 N Massachusetts San Bernardino CA Version 12 09 May 8 2013 C4Yourself External User Guide C4Yourself Mobile Application As of November 2012 you will be able to use the C4Yourself on line e Application pages from any smartphone has gone mobile Access to Your Benefits Anytime Anywhere START TODAY Es A 4y ourself Scan with Access to Benefits Simplified Any Smartphone Anything that you can do in C4Yourself from a computer you can do from your smartphone The Application Process The rules for applying for cash aid food and nutrition services and or medical services are a little different from program to program but they all start by asking for certain information in writing The C4Yourself on line e Application gathers most of the information you will need to give After you send your application to the county a Case Manager will review the information you gave and decide if more information is needed The more information you can give through C4Yourself the better Version 12 09 May 8 2013 C4YourselfExternal User Guide After sending your application to the county you may be scheduled for an interview This interview may take place of over the phone in person at a county welfare office or in your home During the interview the Case Manager will go over the application and ask you more questions to complete the appli
10. Savings Bonds Life insurance policies Home Land Trusts Housing Rent Mortgage Property taxes Costs Uttties Homeowners insurance Garbagetrash collecton fees Medical expenses Itzeg amp supplies Transporta on Expenses Health insurance s NN ieee Room amp Board Child dependent Chid spousa support Housing costs Penalties a on purpose you PENALTIES FOR CalFresh FRAUD H on purpose you do 17 The QR 7 form will have information about your Case already completed This information includes e The county s address telephone and fax number e Your case manager s name worker ID and telephone number e The date the form was created e Your Case Name Case Number and mailing address Version 12 09 May 8 2013 C4Yourself External User Guide 18 Read the instructions carefully There is a lot of information about what types of information you need to report Notice that most questions ask that you ATTACH PROOF You must send proof 19 Answer all the questions and give the information asked for LI NOTE The information you entered will not be saved on the computer you are using It will be sent to the county when you sign it electronically If you want to keep a copy for your records or give it to your county through the mail or in person print it BEFORE you click Save J 20 Read the Certification Fraud Warning 21 Enter the Date and phone numbers Load Pha L J I9bM
11. Signing a document with an eSign User Name and eSign PIN is the same as writing your name on a paper document These eSign IDs are not the same as the C4Yourself login User Name and Password D It is important to know that you are signing under the penalty of perjury This means that you are saying that all the information you gave is true Creating a New e Signature The first time you submit an application through C4Yourself you need to create an e Signature account by setting up an eSign User Name and an eSign PIN A separate and unique eSign Username and eSign PIN is needed for each person who signs the document Typically each adult who is applying for assistance must sign the application Once you create an e Signature account for each person their name will appear in the Person drop down list on the signature part of any document that accepts an e Signature 1 Read all the information on this page 2 Select Create New E Signature from the Name drop down 3 The Create a New E Signature page appears Version 12 09 May 8 2013 100 C4Yourself External User Guide Home Help CAY ourself Access to Benefits Simplified Create a New E Signature You may use this page to create a username and PIN which is unique to you or a particular person on this C4Yourself account It should be different than the C4Yourself username and password you are using This username and PIN will be asked for everytime thi
12. political affiliation marital status sex disability or age If you feel you hawe been discriminated against you may call toll free 1 866 741 6741 or for the hearing impaired TDD 1 B800 6858 44566 I understand that any CalFresh household adult member ewen if they mowe out member or the authorized representative of residents in an eligible institution may be required to repay any benefits the household should not hawe received I understand that my case may be selected for additional review to ensure that my eligibility was correctly figured and that I must cooperate Tully with county state or federal personnel in any iInvwestigation or review including a quality control rewiew I understand that any member of my household who is avoiding or running from the law to awoid a felony prosecution custody or confinement after conviction or is in wiolation of their parole or probation cannot get cash aid CalFresh or CMSP I understand that anyone who has been convicted since August 22 1996 of a drug related felony for possession use manufacturing sale distribution of a controlled substance or any activity in connection with these unlawful acts or harwesting cultivating or processing marijuana or involving a minor in the abowe activities cannot receive CalFresh benefits Your SSN will be used to check identity to prewent duplicate Participation and to werify eligibility and benefits The SSN will be used in
13. 09 May 8 2013 C4Yourself External User Guide 3 Review the information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Child Care page with the information you entered so you can change it Clicking takes you back to an empty Child Care page so you can start over with this page 4 lf you have more child care information to add click es and repeat the process for each person in your household 5 Click co or Next if the information is complete The Medical Treatment page appears Saving an Incomplete Application If you are unable to complete the application process in one sitting you can save the information you ve entered and come back later to finish 1 click Eh J Home My C4y ourself Help ce CF ou rselt S Send A lication Exit Access to Benefits Simplified Send Application U Start Avo lication Expenses Child Care Here its the summary of what you told us so far If wou want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remowe button Money paid byw wou 40 00 How often Mom Chih waho gets care Bea Seymour Momey paid by other Yourself Does anyone else in the home pay all or part of their child care costs CED The Exit page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide ee G ns Home Help Cambiar idioma Exit Your
14. 1 NIRVANA LANE SPACE 12 UTOPIA CA 92335 San Bernardino County 3 Click the button beside the correct address 4 Click ew Tell us more page appears C4YourselfExternal User Guide ag 5 Read the instructions and enter your information as completely as possible Start Application 0 Tell us more Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and McC is for Medical benefits You will need to answer these questions if you have applied for those programs Please give us additional information about yourself If you can not answer a question you can skip it Cw CF Mc Cw CF McC Cw Cr McC COW CF MC CTW CF ME Cw CF MC Are you male or female Maiden Name Date of Birth Social Security Number Marital Status Are you any of these You can select more than one Select One EA E Elderly 60 and older CT without money for food CT Disabled Blind Pregnant E Migrant Seasonal Farmworker 6 Click The Background Information page appears 7 Read the instructions and enter your information as completely as possible Version 12 09 May 8 2013 C4Yourself External User Guide Start Application Hm Background Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will
15. 2013 C4YourselfExternal User Guide us My Messages My Things To Do My Benefits My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Status Due Date Mail in Cover Sheet Verification Request List Ze 09 19 2012 _ Fax Cover Sheet St gt 3s Reports Status Due Date CMSP Rights and Quarterly Eligibility Status Report Editable 09 06 2012 Responsibilities CMSP 219 Statement of Facts Status Due Date Rights and Responsibilities oO Sessently have no statement of facts documents SAWS 2A Upload My Documents Register to Vote You currently have no documents pending upload Select Document To view forms you must have Adobe Reader 16 Click the Quarterly Eligibility Status Report link text A separate window will open with the form that you need to complete i Sa nttps www c4ydemo c iv com docType 05 amp FMSNumber UqiqKMP9c0s 3D amp tempiat x lt e File Edit View Favorites Tools Help f wie x Google 29 Search More gt Signin A ET Favorites Call Me Live Chat Home Help gaal 725 lille laTiocalastonalacomments F cambiar idioma 1 Highlight Existing Fields My Applications Due Date Quarterly Eligibility Status Report Seymour F Yourself es SPACE
16. Add Missing Application Information link text will take you to the My Applications page You can then edit the e Application by adding the missing information Example The picture below shows the original e App number assigned when the application D IMPORTANT NOTE When your e Application is posted back to your C4Yourself account it is automatically given a new e App Number When you complete the missing information and re submit the e Application it is again given a new e App Number This is done so that each copy of the e Application is saved separately was submitted There is a new e App Number under Applications Missing Information The E App Date stays the date the original application was submitted My Messages My Things To Do My Benefits My Forms My Applications My Applications Start a New Application Click the next button to start a new application Applications for Renewal Recertification fave mo renewals to submit Applications Missing Information E App Number E App Date CiIV 12 256 0064905 08 13 2012 Prewious Applications E App Number E App Date CIW 12 226 008490 0s7 13 2012 1 Click next to the E App Number under Applications Missing Information 2 Go through the application and add the missing information 3 Complete the e Signature page and click Submit Your Application J Version 12 09 May 8 2013 124 C4Yourself External User Guide Home Help C4AY ours
17. Application section The first page of the last section you were in appears Because we had last entered Child Care expense information Version 12 09 May 8 2013 C4YourselfExternal User Guide when we exited the first page we see when logging back in is the Expense Information page 5 Click RES until you reach the first page without any of your information In our sample case that would be the Medical Treatment page Continuing an Application Retroactive Medical Expenses The Medical Treatment page allows you apply for help with bills for medical treatments received in the three months before you submit your C4Yourself application to the county Medical treatments may include services such as e Pregnancy related services e Wheelchairs e Wheelchair repair e Hearing aids e Batteries for hearing aids and or pace makers e Eyeglasses e Therapy e Psychology services e MRIs e Chiropractic care e Acupuncture care e Non emergency transportation for Dr appointments e Physical therapy covered in Long Term Care facilities and e In home services A record for each person who actually received medical care is needed for each month that the person received care In our sample case our application month is July 2012 Bea Yourself had a doctor visit in May and had a prescription refilled in June Version 12 09 May 8 2013 e C4Yourself External User Guide Select the person select the month in which the medical c
18. BE PAID BY ADDRESSEE Number a0 422 4031 Ext 358 San Bemardino Case Name 150 South Lena Rd anal San Bemardino CA 92415 515 Please Stop My Benefits For Cash Aid CalFresh C Medi Cal at the end of this month Sign and date the last page Return the fomi to your worker You can reapply St any time PART 1 Please tell us what happened tn August 2012 REPORT MONTH TEAR 1 Did you or anyone get any income or money from any Source this MONTH If YES list below and ATTACH PROOF O ves O no Eamings Babysitting interest or dwidends rental come salary deren il cation pay etc Any Govemment Benefits State Disability Indemnity SON Social Security Supplemental Security lncome State Supplementary F SUE other Qowermnnent Ods avitv or retirement rental assistance unemployment veteran s retirement Worker Compensation UIB e H Other Benefits Child spousal support Insurance or legal setiements oter private disability or retirement reload retirement strike benefits etc Other Cash gifts loans scholarships etc Income In Kind Such as samed housing free housingfutlites aathingiaod etc eege E A A RI y kenen EEN WR ER RR KS ib if the income or money reported above will change in the next three months after the SUBMIT MONTH please explain and ATTACH PROOF Name of person Source of income of money Why will it chamge ee TS ane Mone Thira Month S a Ste ue ata oir A Et n RN en Et E lf YES li
19. Click the Register With My County link text y Messages bh My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application BEE Manage My Account Profile This information will be used throughout the application for identification purposes Manage My Applications Renew Recertifty My Benefits Manage My Forms and Status Reports Sign Statement of Facts 7 Click the Request a link to your case s link text Version 12 09 May 8 2013 C4YourselfExternal User Guide My Messac My Benefits My Forms My Applications My Things To Do You can use this page to renew or finish start a new application Manage My Account SS E EN i a x Register With My County Beguest a link to your Casel This will let you view benefits forms and information about your existing case s through your C4yYourself account Add Missing Application Information 8 On the Register With My County page enter all the required information You will need your Case Number My Me My Forms My Applications Register With My County You can register your account with your county to receive case specific information You must answer questions marked with Middle Name CV iii LastName Baily Social Security Number LE E siti is Osteo Eire a 1974 f Are you male or female Si Male Female Address L
20. Even if you did not apply for public assistance through the C4Yourself on line e Application you can use tt to View Messages from the County Manage your C4Yourself Account including o Manage your profile o Register with your county o Deregister from your county Manage your Applications including o Renew Recertify your benefits o Start a new application o Finish Saved Incomplete un submitted applications o Add missing application information o See prior applications Manage Forms and Status Reports o Signa Statement of Facts SAWS2 o See Pending Verifications o Complete a Status Report o Report changes Check your current Benefits View Forms that your complete print and mail fax or drop off at your local office Send forms electronically upload to the county See and access applications that you have submitted in the past or submitted but are missing information and Start a new application Version 12 09 May 8 2013 C4YourselfExternal User Guide My Messages There are many reasons a Case Manager may need to send you a message Your C4Yourself account allows you to get messages from the County safely and securely When you give the county your e mail address you will get an email letting you know a message for you has been posted to C4Yourself You can then login to C4Yourself to get the message 1 Click the Check Messages link text on the C4Yourself home page The Login page appears Jpn Ss W
21. Expedited Service within three days Here are some reasons why you may be entitled to Expedited Service Your household s gross income and liquid resources are less than your rent mortgage and utility costs the total monthly gross income of all the people in your household is 150 or less or you are a migrant or seasonal farm worker with less than 100 CalWORKs The CalWORKs program is temporary cash assistance for families with low or no income It also provides education employment and training programs to help families get jobs Child care transportation work expenses and counseling are available for working families You will be automatically tested for Medi Cal and do not need to check the Medi Cal box below Medical Checking this box allows the county to determine eligibility for programs that provide medical assistance to adults and children P Back 2 Click The Your Information page appears Version 12 09 May 8 2013 C4Yourself External User Guide Your Information The Your Information page is where you start to give information about yourself Questions with a star require answers so that the county can track the e Application back to you to finish the application process 1 Read the instructions and enter your information as completely as possible Start Application Your Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF
22. Honorable Discharge yas Le Enlistment Date January Le 05 Le Discharge Date January 31 ls Branch of Service Select One Je Honorable Discharge Select One Enlistment Date Month gt Day Discharge Date Month Dayi Next 2 Click to see a summary of the military service information you ve entered Version 12 09 May 8 2013 C4Yourself External User Guide Start Application ah Expenses Property Military Service Here is the summary of what you told us so far If you want to change information for anyone click the Edit button If you want to remove the information for anyone click the Remove button re SS ZE P E ee r Be aio ao Ee Bees 01 05 2004 01 31 2009 Seymour Yourself Has anyone else in the home served in the U S military or is the spouse parent or CE child of a person who served in the military ji l Next 3 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Military Service page with the information you entered so you can change it Clicking takes you back to a blank Military Service page so you can start over with this page 4 If you have more income from military information to add click Yes J and repeat the process for each person s military service information 5 Click No or Next J if the information is complete The Additional Services page appears V
23. LEJ yes Pa 11 ee l a yeting ad or beneti up e A Be atb oi WE a oR Be ra We Geer Sepie tz H g gem Ip ee se d Eligibiiiyi Staus Ol MUST SIGN AND DATE THIS F REPORT AFTER THE LAST DAY OF THE MONTH THIS REPORT S FOR OF IT WILL BE CONSIDERED Iran ei lw TT underlie ave lr Je eu BE e AE hat Haci AA ts report are iue and correct and complete WHO MUST SIGN BELAN For Cash Ald you and your aided spouse domesic partner and ine other parent of casn alded children E Ing in the Pome For CalFiraeh the head of household a responsible howsenold member or the household s authorized representative SIGNATURE OF MARE DATE GNET HOME PHORE COATACTICELL FHONE 4 SIGNATURE OF SPOUSE DOMESTIG PARTNER GR TI DATE 2IGHED SIGNATURE GF AITHES TO MARK INTERPRETER GR DATE SIGNED OTHER PARENT OF CASH AIDED CHILD REN OTHER FEREON COMPLETING FORM GAT i208 REGUIRED FORM SUBSTITUTES PERMITTED Page 4 of 4 III III D TUETOIHT OR 21 7 3606085 IA AE TOS 22 Click the printer icon O KI https www c4ydemo c iv com doclype 05 amp FMSNumber UqiqKMP9c0s 3D amp templat mme e File Edit View Favorites Tools Help x Google We Favorites zs 29 Search Mores Signin amp Call Me Live Chat Home Help m m S 1 74 725 i7 Sign Ig torm You cannot save Gata Typed into tnis E My Applications County of San Bernardino
24. Manage My Account Profile Manage My Account Profile Update your profile information This information will be used throughout the application for identification purposes Information 3 Click the Deregister from My County link text on the left Version 12 09 May 8 2013 120 C4Yourself External User Guide My Messages My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application Manage My Account Manage My Account Profile Register With My County l en i EE DESCH Once deregistered you will not be able to view the case informa tion you ie were linked to unless you request another link Deregister From My County Dereaister the link to your casefs eS EE TEE A Renew Recertify My Benefits Start New Application Finish Saved Incomplete Unsubmitted Applications Add Missing Application Information 4 Click the Deregister the link to you case s link text on the right The Deregister from my County page appears CAY ourself Access to Benefits Simplified Cambiar idioma My Messages My Benefits My Forms My Applications Deregister From My County By clicking next you will send a request to your county office to remove any connection between this account and your case s You cannot undo this request If you click the next button below and change your mind about deregistering you will h
25. May 8 2013 C4Yourself External User Guide What Types of Assistance can Apply for through C4Yourself ccccccccsseeeseeeeeeeeeeeeeneeeaes 30 ISAS TST Gs ANG SS E E AE E E A E E 30 A Tee 31 Why Create a User Account 33 Create a C4Yourself User Account 34 LOO eea EEE E EEEE E EERS 37 forgot my Login information ccccceecceeeceeeceeeteeeceeeceeeeeeeceeeeeeeseueeaeeteeeseeeeaeeteeeteeeseeeseeeseees 37 GANIE S LVE GAAT arane E EEEE EE EEE EEE TEE AEE 39 Call Me and Live Chat Avalabuify 39 lee 39 Ru e d 40 VC e TE 43 Greate an ACCOUNT tient ca samnoencnnantnaaniananiteanhsaadanasneiniet sdk hana EEE 44 Starting an C4Yourself e Application cccccceececseececeeeeeeeeeceeceseeeeeseeeeseeeeeseeeesseeeeseeeesaeeeeas 47 eg dee fc E 47 OUT ATO FINA Ia E 48 Ktel t lv ev Io NEE 50 Julie Ee HE 51 Expedited le 51 JOD MOM Ee EE 56 HCO gin el UO E 59 Expense MIONA EE 62 WIIG Care en E 62 Saving an Incomplete Application cccccceecccseececeseeceeeeeseeeeseueeeseeeeseueesseeeesseesseeeseeeesseeesaes 64 Open Saved E ele icc aveccdsiectsncetenccedslentanct bounced isnt ansttowtendbientannt tewsenetiandueethoweeccsinatsansiooted 65 cConin ing aN APPICINON EE 67 Version 12 09 May 8 2013 Retroactive Medical Expenses ccccccccececeeeceeeceeceeeceeeceeeceeeseeeseeeteeeteeeeseeseeseeeseeeseeeseees 67 Oller Heal COVCV AG eeeessgedegengesgeeesge EKEREN EREA LANDRA eege ERR egEueeg 71
26. PIOUS ING ge 73 Bil T5 Property Information HE 76 Income from Property E 83 MOtOr E e 84 Oler tee 87 AUTOZ ATION E 90 Ve ee e E tcc penne ae ec E E A A E A E T 91 Additional Sarvi ES sssrin aE a a aE 93 Application UIA ec E 95 Your Application is ready for submteeion 97 Disclaimer Right Responsibilities and Other Important Information 98 lef 99 Creating a New e Signature ccccccccceeccceeeeeceeceseeeeeseueeseeeeeseueeseeeeeseeessueeeseusessaeetseeessneeess 99 What else will having a C4Yourself Account will do for Mei 106 MY WIC SSAC E 107 EE 109 MY TANO re Ee dE 110 Manage My NG COU E 111 Manager My Account Profile cccccccecccececeeeseeeseeecececeeeceeeseeeceeesseeseeecseesseeseeeseeeteeenes 111 Register with My County E 111 Deregister with My Coumty 118 I PHC AMON EE 121 Start a New ADDIIC ANON DEE 121 Version 12 09 May 8 2013 C4Yourself External User Guide Finish Saved Incomplete Un submitted Applcaion 122 Add Missing Application Information ccccccccseeeceececeeeeseeeeeeeseueeseeesseseseeeeseeeseueeseeeeaes 123 AEN 125 MY ei EE 128 Access the My Forms page 128 Ma il in Cover TE 129 View and Print Rights and Responsibilities 2 0 00 cccccecseccseeeeeeeeeeeeeeeeeeeeeeeeeeseeseeseeeeeees 130 Register to Vote EN 131 R ylelleiekt ville le 132 Upload My WD OCUIMI CNIS ise ccesncaseceonaceasennsssiensacceganesancsantannchessoudagnesbaseaeuesanncanseancesaoansantneacenes 135 e
27. Read our Privacy Statement Messages are listed by date with the Subject as a link 4 Click the Subject link text The message will appear Version 12 09 May 8 2013 C4YourselfExternal User Guide 409 EE a a Call Me Live Chat Home Help CAY ourself Ja Access to Benefits Simplified English Cambiar idioma My Things To Do My fit My Forms My Applications Key Dates in August 2012 Message Inbox Sun Mon Tue Wed Thu Fri Sat Subject Date b PER Appointment 08 28 2012 Hello Ms Yourself I have sent you an appointment letter for your initial D D DI 415 E DAD l i interview Please bring the Verifications listed on the letter with you Your 19 20 21 22 23 oa 25 daughter does not need to come 2s E 28 23 E e Apopllication Received 06 22 2012 Fatere Date Hello my name is Super Worker I just wanted to let you know that I got your e Application for CW CF amp MC today I will review it and contact you within the next 3 days to finish the process Thank you Once you ve read a message you have the choice to remove it or the simply close it by clicking Key Dates The Key Dates Calendar shows the days the County will be closed for Holidays Version 12 09 May 8 2013 110 C4Yourself External User Guide My Things to Do You can use this page to manage your C4Yourself account manage you applications and manage forms and status reports When you click the li
28. See your remaining EBT balance Announcements View information about your existing case s through your C4Yourself account Click here to log in IO aa og ag C4yYourself Is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Priva Statement OED PED vasiy gt 2 Log in with your User Name and Password The My Forms page appears C Aen Arse l f Call Me Live Chat Home Help Access to Benefits Simplified My Things To Do My Benefit My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Due Date Mail in Cover Sheet Verification Request List Viewable 09 19 2012 Fax Cover Sheet Status Reports Status Due Date hy Status Report Viewable 09 06 2012 Statement of Facts Status Due Date SAWS 2A You currently have no statement of facts documents Register to Vote Upload My Documents You currently have no documents pending upload Select Document To view forms you must have Adobe Reader ct Docume 3 Click Wa the Send Documents page appears Version 12 09 May 8 2013 138 C4Yourself External User Guide Home My C4Yourself Help CAY ourself Access to Benefits Simplified Please provide information s
29. The list below is what the worker may need before we can approve your application Identification Immigration Status Sponsored Noncitizen Information Residency SSN Application for all Household Members Income Earned Unearned or from self employment Property Assets Utility Expenses Shelter Expenses Medical Expenses Child Support Obligations and Payments Pregnancy School Grants or Loans lt may be helpful to print this list for future use If the computer you are using is connected to a printer you can print this page by following these steps 1 Make sure the computer you are using is connected to a printer with paper 2 Click the Ctrl key P the Print screen appears General Select Printer i sd ADFDPR13 on adfdfs01 ae Microsoft XPS Document Writer ies Black and White Copier mg Send To OneNote 2010 ae Fax ee Snagit 11 4 t Status Print to file Location Comment Find Printer Page Range All Number of copies 1 5 Selection 5 Current Page D Pages 1 Collate a UU gt 12 3 Enter either a single page number or a single Eit EE ER page range For example 5 12 Version 12 09 May 8 2013 C4Yourself External User Guide IMPORTANT NOTE This print process is part of the computer s settings not part of the C4Yourself on line e Application If there is a problem printing check the computer s print settings This process can be used to print any page in the C4Your
30. There are two types of Kiosks Blue C4Yourself kiosks pictured below are available to complete C4Yourself on line e Applications and upload documents After you have scanned your document you will get a receipt like the one pictured above Red C IV Kiosk Red C IV Kiosks pictured below are for uploading documents only These kiosks are usually placed in the lobbies of Social Services agencies Version 12 09 May 8 2013 C4Yourself External User Guide Upload My Documents You can use this process to upload documents that are stored on your computer as either a PDF Portable Document Format or a TIFF Tagged Image File Format To upload to C4Yourself these documents must be 2 MB or less in size 1 Select the View Forms link text on the C4Yourself Home page Version 12 09 May 8 2013 C4YourselfExternal User Guide C Y ourself Arenas EE Apply for Benefits Start an application Cash Assistance Food amp Nutrition Medical My C4Yourself If you have already created a C4Yourself account you can log in by following the links below Check Messages Check Benefits Open Saved Applications C4yYourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe C4Yourself California Counties you can send your application Contact the Coun about your existing case
31. To apply contact a local office to schedule an interview The postpartum period is a period of 60 days beginning on the last day of pregnancy To reapply is to apply for a program is to submit an application for a program within 30 days of being discontinued from or denied for that program A renewal is an annual re evaluation or redetermination of your eligibility Usually in the 11 month of aid you will be asked to fill out another application so the county can see if your family s eligibility will continue or renewed for the next year This term is usually used for Cash Aid See also Recertification May 8 2013 C4YourselfExternal User Guide a Meaning Recertification Recertification is the same as Renewal but this is used by the CalFresh program Statement of Facts The Statement of Facts also called a SAWS2 is a generic application form used for CalWORKs CalFresh and Medi Cal When the information gathered through C4Yourself is sent to the county A Case Manager reviews the information and if appropriate links it to a case number in the C IV System When all the needed information is gathered and verified the C IV system will create a SAWS 2 form This form can be printed and physically signed by the applicant s or it can be signed electronically then printed Either way the signature is provided under penalty of perjury See Fraud and Perjury SUD or Substance Substance related disord
32. abuse treatment counseling sexually transmitted diseases STD or sexual assault Version 12 09 May 8 2013 C4Yourself External User Guide Fingerprinting 2 Q A 3 Q A 4 Q A 5 Q A Is it true that I have to be fingerprinted in order to get help All adults applying for CalWORKs or County General Assistance General Relief GA GR are required to be fingerprint and photo imaged into the Statewide Fingerprint Imaging System SFIS What is SFIS SFIS the Statewide Fingerprint Imaging System is a computer system and database containing fingerprint images photographs and case information of adults who have applied for CalWORKs or County General Assistance General Relief What happens during the SFIS Process You will be asked to place each index finger on an electronic scanner The scanner will take a picture of your fingerprint Your picture will also be taken These pictures along with your name and case information will be entered into the SFIS database The pictures will be compared to the pictures of others who have applied for aid Is it true that this is used for criminal background and immigration status checks No SFIS is confidential It is used only to prevent public assistance fraud SFIS is not connected to any other system or database Version 12 09 May 8 2013 C4YourselfExternal User Guide ER 6 Q What happens if don t go through the SFIS process A Your appl
33. anyone own have the use of or have their name on the registration of any motor vehicle even if not running Next Version 12 09 May 8 2013 C4Yourself External User Guide 2 Click Next J The Own Property page appears 3 Read the instructions then select the person who owns the property and complete the information as completely as possible Start Application Own Property You told us that someone might own property or is buying property somewhere Please tell us more about these people Select the person and add their information You can select more than one person P P p p w Inte atic Property Used As Property Type Amount Owed Date expected to return to property Lien on Property Address Property Used As Property Type Amount Owed Date expected to return to property Lien on Property Address Home E Rental of Land Buildings Personal Property Le Day Le Year ha A L Home Rental of Land Buildings Personal Property Select One ha Month EA Day EA Year EA Select One ls 4 Click the Edit Address button The Address page appears 5 Enter the address of the property Version 12 09 May 8 2013 C4YourselfExternal User Guide Start Application People Address You must answer questions marked with Address Line 1 1 Nirvana Lane Address Line Space 12 City Utopia starte California Ei zip Code 92733
34. application has been saved to your username C4Yourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement Verisign UED Secured VEBiP ee Open Saved Applications Once you have save an e Application you can return to finish anytime you want 1 On the C4Yourself Home page click the Open Saved Applications link text Bee Gale etal Access Cambiar idioma Apply for Benefits Cash Assistance Food amp Nutrition Medical av 6 TA My C4Yourself A ccess t O B ET ef its i S i m p ifi e d S If you have already created a C4Yourself account you can log in by following the links below Create an Account C4 4yYourself ste an online application system that View Forms allows you to apply for benefits This is a secured site and all your information will be private and safe Cc4Yourself California Counties See a map and listing of all C4 Yoursell counties where you can send your application Announcements View information about your existing case s through your C4Yourself account Click here to log m 1 4 oF 1 C4yYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement Werlsiaqn OED Secure VEG 3 oe Version 12 09 May 8 2013 Les C4Yourself External User
35. be eligible to CalWORKs e Are actively looking for a permanent place to live IHSS In Home The In Home Supportive Services program will help pay for Supportive services provided to you so that you can remain safely in Services your own home To be eligible you must be over 65 years of age or disabled or blind Disabled children may also be eligible to IHSS Immediate Need Immediate Need in not a program but a CalWORKs IV D IV D Child Support Kin GAP The Kin GAP program offers funding to children who leave the juvenile court system to live with a relative legal guardian LIHP LIHP is a Health Care program that is available to adults Version 12 09 May 8 2013 payment method that if you qualify and it looks like you will be eligible to CalWORKs would let you to get up to 200 to help you until the application process is finished lf the family includes a child aided by CalWORKs whose parent is not living with the caretaker the County will automatically notify the local Child Support Agency LCSA The LCSA will provide all necessary child support services including establishing paternity establishing and enforcing a support obligation and collecting support payments If the child s paternity has not been previously established the adult caretaker is required to help the local child support agency do so This may mean participating in an interview and submitting the child to blood testing if the alleged parent once c
36. before the entire application process is finished Version 12 09 May 8 2013 C4YourselfExternal User Guide a Immediate Need CalWORKs has a process called mmediate Need that if you qualify and it looks like you will be eligible to CalWORKs would let you to get up to 200 to help you until the application process is finished Expedited Services CalFresh has a similar process called Expedited Services that if you qualify would let you get CalFresh benefits within 3 days of turning in your application To be eligible for Expedited Service you must be eligible for CalFresh AND have e Rent or mortgage and utility costs that are more than your liquid resources and this month s income before deductions OR e No more than 100 liquid resources and less than 150 income before deductions for the month OR e No more than 100 liquid resources and at least one member who is a migrant or seasonal farm worker 1 Read the instructions and enter the information as completely as possible Start Ayo ica Down O Your Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and McC is for Medical benefits You will need to answer these questions if you have applied for those programs OK You are almost finished with this section Cw CE Mc How much is your rent mortgage this month OSCH DO CF How much are your utilities this month if 2
37. benefit and income facts will be matched with local state and federal records such as employers the Social Security Administration tax welfare and unemployment agencies etc and for cash aid and CalFresh records well be matched with law enforcement agencies for arrest warrants I understand that the county will send information to the U S Citizenship and Immigration Service USCIS for Werification of noncitizen status and to the Social Security Administration to check work quarters information for noncitizens applying for benefits This process may include confirmation with the U S Citizenship and Immigration Services USCIS formerly INS of the immigration status only of those persons seeking CalFresh benefits Federal law says the USCIS cannot use the information for anything else except cases of fraud I understand information including benefit and income facts that I hawe Given on this form is subject to inwestigation and review by county state and federal personnel and that if I give incorrect facts my benefits may be denied or stopped I understand that I must apply for and keep any available health coverage if no cost is involwed if I do not my Medi Cal will be denied or stopped I understand that I or other family members will be required to repay any cash aid I should not have received Ii understand I hawe the right to be treated equally without regard to race color national origin religton
38. benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs If you can not answer a question you can skip it CW CF Is this child a foster child MC Is this child 18 21 and claimed as a dependant for tax purposes Te 10 Click The This is who you have told us about so far page appears Start Application People This is who you have told us about so far Here is a summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Bea Yourself Is anyone else in your home Yes Ne Te 11 Click co i if the information is complete The Job Information page appears Version 12 09 May 8 2013 C4Yourself External User Guide 12 If you have more people in your home click Yes J and repeat this process for each person Summary pages let you check the information you just gave You can edit and or remove incorrect information Clicking Edit takes you back to the Information about the people living in your home page with the information you entered so you can change it Clicking takes you back to a blank Information about the people living in your home page so you can start over with this page Job Information The Job Information pages gather information about
39. computer matches to check your Income and resources with records from tax welfare employment the Social Security Administration Income Eligibility Werification System LEWS and other agencies Differences may be checked out with you and with employers banks or others Making false statements or failing to report all facts or situations which affect eligibility and aid payments for Cash Aid CalFresh and Medi Cal CMSP may result im repayment of benefits and or criminal Or ciwil action TFT declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained in this statement of facts is true correct and complete Seymour Yourself 04 29 1972 Seymour ra esign Pim Signature Parent or Caretaker Relative Medi Cal Applicant Adult CalFresh Household Member or CalFresh Authorized Representative Select One e2Ssign PIN Signature Other Parent Living in the Home if applying for cash aid Select One Username esign PrN Description Signature of Witness to Mark Interpreter or Person Acting for Applicant Beneficiary Please select your name and enter your eSign Username and eSign PIN Click the Submit Your Application button to send your application Version 12 09 Submit Your Application May 8 2013 104 C4Yourself External User Guide 8 Select you name from the Name drop down Enter your eSign Username and eSign P
40. documents to your county office Blank Forms Pending Verifications Status Due Date Mail in Cover Sheet You currently have no verification documents Status Reports Status Due Date You curently hawe no status reports Statement of Facts Status Due Date You curently hawe no statement of facts documents Upload My Documents You curently hawe no documents pending upload Select Document To wiew forms you must have A4dohe Reader 2 The form will appear in a separate window Register to Vote The National Voter Registration Act of 1993 also Known as The Motor Voter Act was enacted to help increase voter turnout by making it easier to register to vote You can now register to vote or update your voter registration on line My Things To Do My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Status Mail in Cover Sheet You currently have no verification documents Fax Cover Sheet Status Reports Status Due Date You currently have no status reports Statement of Facts Status Due Date You currently have no statement of facts documents Upload My Documents Register to Vote You currently have no documents pending upload Select Document To wiew forms you must have Adnohe Reader Version 12 09 May 8 2013 C4Yourself External U
41. education employment and training programs to help families get jobs Child care transportation work expenses and counseling are available for working families You will be automatically tested for Medi Cal and do not need to check the Medi Cal box below Medical Checking this box allows the county to determine eligibility for programs that provide medical assistance to adults and children Entering dollar amounts It is not necessary to enter the symbol when entering dollar amounts Just enter the numbers like 105 000 You will get an error message if you include the symbol Property Used As Home _ Rental of Land Buildings Personal Property Property Type Seymour Amount Owed Yoursel House 105 000 There is a problem with how you entered this It needs to be something like 150 00 y Dayle Year m Date expected to Month return to property Version 12 09 May 8 2013 C4YourselfExternal User Guide C4Yourself Home page The C4Yourself Home page provides a starting point for exploring many options for getting information about the types of public assistance available and how and where to apply for those benefits ct Yourself Access to Benefits Simplified Apply for Benefits Start an application Cambiar idioma Medical Cash Assistance Food amp Nutrition My C4Yourself If you have already crested a C4yYourself account you can logti
42. fill out and mail FAX or drop off at your local office You can also upload documents to your county office Pending Verifications Status Due Date Mail in Cover Sheet You currently have no verification documents Status Reports Status Due Date You currently have no status reports Statement of Facts Status Due Date SAWS 2A You currently have no statement of facts documents Register to Vote Upload My Documents You currently have no documents pending upload Select Document To view forms you must have Adobe Reader 2 Select you County from the drop down list Click 3 A list of the office in the county appears My Things To Do Moy Benefits Moy Applications Select an Office YUCCA VALLEY TAD ESP CHILD CARE PID 260357 PIMA TRL YUCCA WALLEY CA 92284 877 410 8829 De VICTORVILLE TAD ESP CHILD CARE PID 15010 PALMDALE RD VICTORVILLE CA 92392 2546 877 410 8829 COLTON TABD ESP CHILD CARE FC PID 2040 WOODPINE AVE COLTON CA 92324 1822 877 410 8829 REDLANDS TAD CHILD CARE WIA PID 881 W REDLANDS BLYD REDLANDS CA 92373 8009 877 410 8829 ADELANTO TAD ESP CHILD CARE 10875 RANCHO RD ADELANTO CA 92301 877 410 8829 To SB TAD 01 ESP CHILD CARE PID 265 E 4TH ST SAN BERNARDINO CA 92410 877 410 8829 TWENTYNINE PALMS TAD ESP CHILD CARE PID Version 12 09 May 8 2013 C4Yourself External User Guide 4 Click Next The Mail Cover Sheet appears with date time and the na
43. for electricity water telephone propane sewage garbage and trash 1 Read the instructions and enter your information as completely as possible Start Application People income Expenses Utility Costs You told us that someone in your home pays for utility costs Please select the people and fill in the information below You can only select one person but you can select more than one type for each person AA Seymour Bea Yourself Yourself Gas Water Telephone basic rates for one phone plus tax Heating or cooking fuel propane wood Sewage Garbage or trash Installation of utilities E C E iM a a a aa Other explain Version 12 09 May 8 2013 C4Yourself External User Guide 2 Click to see a summary of the utility cost information you ve entered Start Application People J Income Expenses Utility Costs Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button lectricity Moniy Water Monthly Telephone basic rates for one phone plus tax Op Monthly Edit Heating or cooking fuel propane wood Quarterly Sewage Monthly Garbage or trash Monthly i L Seymour Yourself Does anyone else in the home pay utility costs CH No TT 3 Review the information As with other summary pages you can edit or remove incorrect in
44. in the past ca 24 months or planning to work in the next two months l l Next 5 Review the information As with other summary pages you can edit or remove incorrect information Clicking EEI takes you back to the Job and Job History page with the information you entered so you can change it Clicking takes you back to an empty Job and Job History page so you can start over with this page 6 If you have more job information to add click Yes J and repeat the process for each job for each person in your household 7 Click co if the information is complete The Income Information page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide em Income Information The Income Information pages gather information about the kinds of income the people in your home get Your answers to the questions on the Income Information page set up which pages you will see next Start Application Income Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs In the next few pages we will ask you about the people in your home who earn or get money CW CF MC Is anyone getting or going to get money from any of these sources This includes children Cash assistance CalWORKs Refugee Assistance CAPI General Assistance Relie
45. link text The My Message page appears with a message for you My Things To Do My Benefits ly Forms My Applications Key Dates in August 2012 oe Inbox a ae E E a B S Thank you for submitti S Is e kk b hoh EE 08 29 2012 az ia fia fis eine is 20 as as fs fez fee fs besi Future Dates 12 Click the subject link text and the message appears Version 12 09 May 8 2013 C4Yourself External User Guide My Things To Do My Benefits My Forms My Applications Key Dates in August 2012 Message Inbox Sun Mon Tue Wed Thu Fri Sat a 2 3 4 08 29 2012 a ove p 3 P P 3 DI ii eqgistration request Jaz jaa ia jas je a7 ly You submitted a request to link your C4Yourself account to your existing cases on 08 29 2012 Once we have processed this request you will receive another message here informing you of the status of your request 19 20 31 22 23 Ga Se 27 ze z9 o al Future Dates 13 Click and the message disappears but is still available Click and the message disappears forever Deregister with My County You can also deregister or de link your C4Yourself account from your active C IV case Household Member Change Example Let s say you and your husband have an active C IV CW FS amp MC case You created your C4Yourself User Account and shared the login information with your husband He is now out of t
46. need to answer these questions if you have applied for those programs Please give us additional information about yourself If you can not answer a question you can skip it cw CFM What is your preferred language Cw CF MC status Cw CF MC Are you sponsored CWY CFE MC What city were you born in CW CEM What state were you born in CW CF MC What country were you born in cw CF MC Are you Hispanic or Latino CW CFM Please give us your race or ethnic origin English What is your citizenship US Citizen No Ka Panama City Flonda United States Le Ho Cl American Indian or Alaskan Native al Asian If checked please select one or more of the following Black or African American w Filipino C Chinese E Japanese O Cambodian C Korean C Vietnamese CO Asian Indian EC Laotian C Other Asian specify El Native Hawaiian or Other Pacific Islander If checked please select one or more of the following Native Hawaiian Guamanian O Samoan Other specify White Cl Unknown 8 Click Net J The next page of Your Information appears Your Information The Your Information page gathers information about the urgency of your needs For instance if you have an age or health related hardship if you have an eviction notice or are unable to pay your housing costs or you have no food in the house you may be able to get some cash or nutrition benefits issued to you
47. previous applications 3 The Lets Get Started page appears ie ri a ome Help Access to Benefits Simplified Let s get started Here are some things to know before you start the application We will be asking you questions about you_and the neople in your home We will need information on how much money you have and the bills you Ge It is helpful if you have zoav stub and the bills you pay like rent utilities and child care You can view a lis of information you may need betpre you start the application After you finish the application you can Serre erteeetr sir on Before you can get benefits the agency may need to get proof of some of the answers you have given In some cases you will also need to talk with a worker over the phone or in person Your local agency will call you or send a letter about this It may take 15 minutes or more to finish all the questions TT We recommend you gather certain information before you start the application and keep it available Giving the county proof of some of your information is part of the application process A list of the most common types of verifications you may need to give can be found by clicking the information you may need link text The Verifications page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide A C AY 0urse Lf S Home Help Access to Benefits Simplified Verifications The worker may ask you to give proof of some information
48. the intended purposes for the cash aid is to help meet the basic needs of my family including housing food clothing e I understand my rights and responsibilities and agree to comply with my responsibilities e I also understand the penalties for giving incomplete or wrong facts or for failing to report facts or situations that may affect my eligibility or benefit level for cash aid or CalFresh and or my Medi Cal 34 County CMSP share of cost e I certify I was given a copy of The Rights Responsibilities and Other Important Information SAWS 2A QR e I also certify that if I applied for Medi Cal 34 County CMSP I got a copy of the MC 219 CMSP 219 and its contents were explained to me I have read the Rights Responsibilities and other Important Information Test 1 As you read place your mouse on the scroll tab on the right side of the gray box and drag down to scroll through the entire document or print it by clicking Print 2 Check the box next to lI have read the Rights Responsibilities and other Important Information THIS BOX CAN ONLY BE CHECKED WHEN YOU ARE AT THE BOTTOM OF THE RIGHTS RESPONSIBILITIES AND OTHER IMPORTANT INFORMATION PAGE 3 Click Next J The E Signature page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide gg E Signature The E Signature page allows you to create an electronic signature account So you can sign documents that you submit over the internet
49. time PART 1 Please tell us what happened in August 2012 Version 12 09 May 8 2013 C4YourselfExternal User Guide ER Frequently Asked Questions Addresses 1 Q How do I enter my address if have a physical address and a P O Box for mail A Each Address Field in C4Yourself has two lines for an address Enter you physical address in the Address Line 1 space and your PO Box information in the Address Line 2 space Start Application Dap Your Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs Please give us information about yourself You must give us at least your name and address If you can not answer a question you can skip it You must answer questions marked with CW CF MC First Name CW CF MC Middle Name CW CF MC Last Name Cw CF MC What is the best way to contact you Address Line 1 1234 Detroit Sreet Address Line 2 PO Box 543 City San Bernardino State California Zip Code 92418 CW CF MC San Bernardino Ka Cw CF MC Contact Number gt Cw CF MC Email MFlynBiggs email com MC Are you applying for No v benefits on behalf of someone else I m a minor teenager and want confidential Minor Consent Services for family planning pregnancy related care mental health drug and alcohol
50. to get money from property Please select the people and fill in the information below You can select more than one person Monthly Seymour Yourself Select One hal a Version 12 09 May 8 2013 C4Yourself External User Guide 2 Click to see a summary of the Income from Property vou ve entered Start Application People ob Income Expenses Property Income from Property Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Monthly Seymour Yourself Does anyone else in the home get money from property they own TT 3 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Income from Property page with the information you entered so you can change it Clicking takes you back to a blank Income from Property page so you can start over with this page 4 If you have more income from property information to add click KO and repeat the process for each type of income 5 Click co or Net J if the information is complete The Motor Vehicle page appears Motor Vehicles The Motor Vehicles pages gather information about any motor vehicle including a car motorcycle scooter RV Campers boat snowmobile etc that is registered in your name or the name of anyone in your househo
51. to someone about this help Are you breastfeeding a child If YES have you given birth within the last 12 months Do you or any family members want free or low cost family planning services to help plan how to prevent unplanned pregnancies and or have the next child If YES call your health care plan or regular doctor Or for facts and the location of confidential family planning clinics call toll free 1 800 942 1054 ws 3 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Additional Services page with the information you entered so you can change it Clicking CZE takes you back to a blank Additional Services page so you can start over with this page 4 Click poche if the information is complete The Application Summary page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide 95 Application Summary The Application Summary page allows you to check the information you entered before you send your application to the county Stall People income EX penses Pro perty Other send Application Application Application Summary You are almost done with your application Here is your contact information Name Seymour Yourself Home Address 1 NIRVANA LANE SPACE 12 UTOPIA CA 92335 Contact Number 909 555 9999 You can click the Next button to go to the next page of the application You can also
52. yetting aid or bell lt A EC EE Se ey ZRS CR EE E gibitty Status 3U MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE MONTH THIS REPORT IS FOR OR IT WILL BE CONSIDERED gee sl nla i alr nr i iwe and corect and complete WHO MUST SIGH BELCAY ar Casel IG yOu 3 IO your z 2 Spouse mesic Parner and Tee er parent OT Ca Seed chliorer ren Fo CalFresh the head of household a responsible howsenold member or fhe howsenod s authorized representaive SIGNATURE OR MARE DATE H5MED or FPHORE Come reg FACE SIGNATURE OF SPOUSE DOMEETEC PARTNER OR AE F DATE ZKGNED OF WITNESS TO MAREK INTERPRETER OR OTHER PARENT OF CASH AIDED CHILD RER OTHER FERGGN GOMPLETING FORM CA T ig REQUIRED FORM SUBSTITUTES FERMITTED j TO A HIH IN H QR TOP 2 i LAAF D Who Must Sign the Status Report The different programs have different rules about who must sign the Status Report For Cash Aid You and your aided spouse domestic partner and the other parent of the cash aided children if he she is living in the home For CalFresh The head of household a responsible household member or the authorized representative Version 12 09 May 8 2013 C4YourselfExternal User Guide ER Other Reporting Requirements There are a few other types of changes that you must report to the count even if it isn t your regular reporting month If you get Cash Aid there are times when you must report information to the county even w
53. you can change it Clicking takes you back to a blank Motor Vehicle page so you can start over with this page 4 lf you have more motor vehicle information to add click Yes J and repeat the process for each type of income 5 Click co or Net J if the information is complete The Other Information page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide Other Information The Other Information pages gathers some general information about your living situation whether you ve received public assistance in the past who you want to be able to use your EBT card if your applications is approved and whether you need more information about medical services The answers to these questions set up which pages you will complete next 1 Read the instructions and enter your information as completely as possible Start Application People Income Expenses Property KC Other Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs In the next few pages we will ask you additional questions about the people in your home CW CF MC Does anyone live in any of these places Homeless Shelter Shelter for Battered Women Drug Alcohol Rehabilitation Center Federally Subsidized Housing Correctional Facility Penal Institution P
54. 00 00 separate from your rent mortgage COW ACF MCE How much money do you have This includes 4100 00 money in a bank account in your home or any other place Cw Cr McC Do you have any of these hardships You can Im You are 65 years old or older select more than one and do not have someone ta represent you I wou hawe a disability and your household members have no income E You live in a remote area elt is hard for you to get a ride or there is not any other type of transportation near you You are sick or care for another household member The weather is or has been bad for a long time Cw CES MC Would you like to hawe a person who speaks Ma your first language help when you wisit the office at no cost H Cw CE McC Do you think you will need help during your Ho interview because you hawe a physical or mental condition Wwe can help you with this cw Do you have an eviction notice or notice to pay Wes or quit cw Have your utilities Deen shut off or do you have a wee shut off notice cw Will your food run out in 3 days or less Wes cw Do you need essential clothing such as diapers Mo or dothing needed for cold weather MM Do you need help with transportation to get Mio food clothing medical care or other emergency item s Wain Nr NM Version 12 09 May 8 2013 C4Yourself External User Guide 2 Click MASS The Information about the people living in your home page appears Notice that the Navig
55. 100 percent state funded program designed to provide Immigrants monthly cash benefits to aged blind and disabled non citizens who are ineligible for SSI SSP solely due to their immigrant status CC Child Care Families that get CalWORKs may also be eligible for Child Care services such as help paying child care costs CFET CalFresh The CalFresh Employment and Training program is Employment and Training CL Cal Learn The Cal Learn program helps pregnant and parenting teens to attend and graduate from high school or its equivalent CF CalFresh The CalFresh Program can add to your food budget to put healthy and nutritious food on the table CHDP Child Health and The Child Health and Disability Prevention Program is a Disability preventive program that delivers periodic health screenings Version 12 09 May 8 2013 California s employment and training program for CalFresh applicants and recipients ia C4Yourself External User Guide Program Program Name Program Description Acronym Prevention and services to low income children and youth in California CHDP provides care coordination to assist families with medical appointment scheduling transportation and access to diagnostic and treatment services Health screenings are provided by enrolled private physicians local health departments community clinics managed care plans and some local school districts CPS Child Pr
56. 12 s Due Date 1 NIRVANA LANE UTOPIA CA 92335 L San Bernardino County of San Bernardino Administrative Service 150 South Lena Rd i 57 Tom ee jeJ our local office E San Bemardino CA 92415 515 Worker Name Sam Sharp Worker ID 3645011270 SC Worker Phone Number 909 423 4631 Ext 368 Date 10 04 2012 Due Date Case Name Seymour Yourself Case Number 2606085 09 19 2012 Loa ve 09 06 2012 to answering all questions on the OR 7 SAWS OR 7 and attaching if you do not send in a complete Attach a separate sheet of paper if needed report inch mot proof when we ask for it your benefits may Be delayed changed or Facts you report may result in your benefits going up down of be stopped Send in your completed report by the Sth of fie month after the report Month Examples Income Wages Sett Employment Salary income In Kind such as earned housing fee Vacation pay Tips Chiid spousal support Interest or dividends housing utities clotung food Insurance or legal Strike benefits H Tax refunds Cash gifts loans scholarships Rental moome and Unemployment Other private or goverment disability or rental assistance Social Security Any government Supplemental Security Workers Compensation benefits Incorne State Veterans or Railroad retrement State Disability Indemnity Supplementary Payment SSVSSP Property Motor vehicles Checking Savings EST balance
57. 5 County San Bernardino as 6 Click Next The Own Property page appears with the address as you entered it Start S Application People VC Expenses Own Property You told us that someone might own property or is buying property somewhere Please tell us more about these people Select the person and add their information You can select more than one person Property Used As EF Home E Rental of Land Buildings Personal Property Property Type Mobile Home Seymour Yourself Amount Owed 98000 Date expected to return to Month Daylily wear le minima Day im Le Lien on Property Ho e Address 1 Nirvana Lane Space 12 Utopia CA 923535 San Bernardino County Property Used As Home Rental of Land Buildings Personal Property Property Type Select One Amount Owed Date expected to return to Month Day Year property Lien on Property Select One Address Edit Address Version 12 09 May 8 2013 Les C4Yourself External User Guide 7 Click to see a Summary of the property information vou ve entered Start Application People J Income Expenses Property Own Property Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Property Information ae Property Used As Home Property Type Mobile
58. Bar that allows you to move through other pages that are specific to you Version 12 09 May 8 2013 C4YourselfExternal User Guide Login Once you ve created your account you can return to it anytime you want 24 hours a day 7 days a week Any of the link texts under Apply for Benefits or My C4Yourself on the C4Yourself Home page will take you to the Login page 1 Enter your User Name 2 Enter your Password 3 Click Next J The My Applications page appears forgot my Login information The secret questions and answers are needed to re set your Login information If you need to reset your password and do not remember your secret questions amp answers you will need to create a new C4Yourself account and then link the new account to your old account using the My Things To Do tab on your MyC4Yourself page 1 Click Forgot your Password link text 2 Enter your User Name and click Neu The Secret Questions page appears CAY ourself Access to Benefits Simplified Secret Questions User Name Seymour Yourself Secret question What is your favorite pastime Your answer Please enter your answer to your first secret question Second Secret question Which phone number do you remember most from your childhood Your answer Please enter your answer to your second secret question Click the Next button to check your answers against our records 3 Enter the answers to your secret questions and click
59. C4YourselfExternal User Guide Your Application is ready for submission The Your Application is ready for submission page will give you a listing of county welfare agencies in the county The offices are listed based on proximity to your home address closest to farthest You can select any office that is convenient for you 1 Select the office you want Home le HA we se el St Fe ft Ed Cees de Seer te tS Ewit Per a i oH hoi Ce 2 HIT AFP Hro Cie JAE aT Peace H income P poe Arm Proga iy CFiharr Your Application is ready for submission Thank wow Your applica hcen if ready Eo be gent Piesate elect the office yow went your Pic eationm Sent ro i EBE TAG CRL ZEZbAZCRAIg ES CARE PICO 265 E 4TH ST DAN BERNHARD CA 2 4 10O LEFF a tO EE ZE ONT ARS TAD ES Py CAL AREY Poo 16a 7 E HOLT ELCH iNT d n Ch El Zen arr 410 8029 TWEEN TTHIME PALMS TAD ESPYCeAILG AREY Pio FAG SUN VALLEY Cre TVENT Y MIME PALMS OCA D2277 25 ze S77 atO LE 23 HESPERLS TEL GARE PIO a STH AWE ESPreRLA CGA 2345 CaF 4 Le ZE FORNTARRA Test CN CARE PIC Sar SIERRA AWE FORNTARA CA SaaS ere 410 825 SEB TAD OF fESPSCHoILD TARE APIO Sas E HIGHLAND AVE BERNARDINO A 92415 0086 corr L n IEC TORMWI LE TAD ESP CHILO ARE Pio Loo PALMDALE EC WIET ORJILLE CA GS a 25A cm gt 410 8829 COLTON TAYE SPY CHIL O CAREY CSPI 2040 Woo DPInNE AVE COLTON Aa StS aes Cos 410 8829 NEL CES TA
60. D ESP Sc Fait CK AREY oe a SYP 1200 BAILEY AE NER ESLE Za 2 ato 277 410 8829 ADELANTO TAD ESP CHILG CARE 10675 RANCHO RG ADELANTO CA 922001 BF7F7 410 8829 EARS TS TAD EPCHIL CAR E A PA 1200 E MAD ST BARS Tay fo So E EFF a tO ER ZEN Ss en ele eier 2050 MLAS SA CHILA DAP BERNARDINO ca es ozas O be 77 410 8829 RANCHO CUCAMONGA TAD SP ooo CAR YP LOGS S RRS ETE RA eS fo Ck Cal SC B77 4210 82820 Tuo ae el Bap Tent Set AS A EP AERCH S6357 PIHA T UCA VALLEY Co Sat ee S77 410 8522 REDLANDS TAD CHILO CAREW LAPIE B61 WW REDLANDS DAC REDLANDS CA 92373 8009 77 410 8820 Po Next 2 Click WEMAS The Disclaimer page appears Version 12 09 May 8 2013 o C4Yourself External User Guide Disclaimer Right Responsibilities and Other Important Information The Disclaimer page allows you to read and print your rights and responsibilities related to applying for public assistance It is important that you READ and UNDERSTAND your rights and responsibilities Home My C4Yourself Help CAY ourselt Access to Benefits Simplified Start 2 SR KEN send Application ple Income Expenses Property Other Application Disclaimer Read all the information below very carefully When you have reached the end of the information check the checkbox on the bottom to indicate that you have read all of the information and agree to the Terms and Conditions provided e I understand that one of
61. External User Guide C4Yourself Windows Internet Explorer McAfee a es 1 _ Choose File to Upload eD J gt Libraries Documents gt Johnson gt C4Yourself User Guides gt Organize v New folder X Favorites Documents library EE Desktop C4Yourself User Guides J Downloads 9 Libraries Recent Places Arrange by Folder Name Date modified Type Size J External 11 8 2012 10 06 A File folder J Internal 7 10 2012 4 24PM File folder Gla Libraries FI C4Yourself User Guide Brief 1 14 2013 10 50 A Adobe Acrobat D w C4Yourself User Guide Brief 11 6 2012 5 03 PM Microsoft Word D Documents Music Pictures A Videos amp Computer MXL151 amp Local Disk C GZ DVD RW Drive D gt Removable Disk 7 File name C4Yourself User Guide Brief 7 The Send Documents page will appear with the document name in the Document field Home My C4Yourself Help cAYourself Access to Benefits Simplified Please provide information so that we can link your document to the appropriate case Note use of this site is limited solely to legitimate Cd4Yourself purposes and any documents or files submitted electronically will become part of the user s case file Submission of any inappropriate material is strictly prohibited Inappropriate material includes but is not limited to the following viruses or malicious code content that is commercial porno
62. External User Guide ua My Things To Do My Benefit k My Applications My Forms Listed below are forms that you may print fill out and mail Es drop oft at your local office You can also upload documepte0 your county office Blank Forms Pending Verifications Status Due Date Mail in Cover Sheet Verification Request List 09 19 2012 Fax Cover Sheet Status Repor Status Sue Date You currently have no status reports Statement of Facts Status Due Date You currently have no statement of facts documents Upload My Documents You currently have no documents pending upload Select Document To view forms you must have Adobe Reader 3 Click the Verification Request List link text The Verification Request List appears in a second window This form will tell you which verifications you will need to send to the county and the date the information is due Version 12 09 May 8 2013 C4Yourself External User Guide BS wee Pre es Wess DU PT LAL JUU Date 09 19 2012 Call Me Live Chat Home Help Case Name Seymour Yourself a I Ge g Verification Request List My Applications Seymour F Yourself SPACE 12 1 NIRVANA LANE UTOPIA CA 92335 drop off at your local office The following is a list of Verifications that arerequired in order to determine and or maintain your eligibility for Public Services or to verify reported information Please provide these verifications hu the du
63. Guide The C4Yourself Login page appears a a e Home Help Ct VY OUrsely Home Hel Access to Bennetts Simplited Camblar idioma Login If thas is your first hme accessing C yYourself please Please enter your User Name and Password in the register a new account here boxes below Click on the Next button and you will go back to the application you were completing Hew Community Based Organization CBO User UserName Seymour yourself If this is your first time accessing C4yYourself please gister a new CBO account here Password 22208 C4yYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement 2 Enter your User Name and Password 3 Click Net J The My Applications page appears i GC Call Me Live Chat Home Help C4AY ourself at Home Help Access to Benefits Simplified English hd My Message My Things To Do ly Benefit My Forms My Applications My Applications Start a New Disaster CalFresh Application new application Click the next button to start a current Application Last modified on 07 30 2012 Apolcations for Renewal Recertification You have no renewals to submit Applications Missing Information There are no applications missing any information Previous Applications You have no previous applications 4 Click the Continue button under the Current
64. Home Amount Owed 98 000 00 Date expected to return to property Lien on Property No Address 1 NIRVANA LANE SPACE 12 UTOPIA CA 92535 San Bernardino County Seymour Yourself Does anyone else own property or plan to buy property 8 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Own Property page with the information you entered so you can change it Clicking takes you back to a blank Own Property page so you can start over with this page 9 If you have more property information to add click ic and repeat the process for each piece of property 10 Click co or Next J if the information is complete The Other Property page appears 11 Read the instructions and enter your information as completely as possible If you have it enter the Address of the bank or company by clicking Edit Address J The Address Page appears The Address page is always the same in C4Yourself Version 12 09 May 8 2013 C4YourselfExternal User Guide a Start Application People Om Expenses Property Other Property You told us that someone might have other property Please select the person and fill in the information below You can only select one person at a time Seymour Bea Yourself Yourself Cash Uncashed 100 Edit Address Check Mortgages Deeds s9000 Edit Address Retirement Plans Edit Address Money Market Edit A
65. Humboldt Imperial Inyo Kern Kings Lake Lassen Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Newada Plumas Riverside San Benito San Bernardino San Joaquin Shasta Sierra Siskiyou Stanislaus Sutter Tehama Trinity Tuolumne and Yuba Counties in California allow you to submit a CalFresh application online For other counties you can print a blank application form from the Food And Nutrition Information Page You can then turn your application in at your nearest social services office ao To make an application on line you will need to create a User Account Click Next Why Create a User Account A User Account is needed to allow you to do the following e Start an on line application e Save the information you ve entered e Re open a saved application that you ve started but not finished e Submit the application to your county electronically e Check messages left for you by your county Case Manager Version 12 09 May 8 2013 C4Yourself External User Guide e View a To Do list of things you must do to complete the application process like send in verifications e Link to your active case even if you didn t apply electronically through C4Yourself e Check your current Benefits Create a C4Yourself User Account 1 On the C4Yourself Home page click the Create an Account link text Ct yoursel ig Access to Benefits Simplified Apply for Benefits Start an appl
66. IN 9 Click SAMU SES The Congratulations page appears Home My C4yYourseli Help Kl CAYourself Access to Benefits Simplified Exit Start B Ge S send Congratulations Your application has been sent to the county office succegSfully The county offe will contact you Please write down or print the following details e App number CIV 12 276 008490 e App Date 08 13 2012 Here is the office your application was sent to 265 E 4TH ST SAN BERNARDINO CA 944 877 410 8829 The e App number is important You may need it if you contact the county office It will help us pull up your application If you are eligible to benefits they will be determined from your e App date Verifications The worker may ask you to give proof of some information The list below is what the worker may need before we can approve your application Identification Immigration Status Sponsored Noncitizen Information Residency SSN Application for all Household Members Income Earned Unearned or from self employment Property Assets Disability Utility Expenses Shelter Expenses Medical Expenses Child Support Obligations and Payments Pregnancy School Grants or Loans Version 12 09 May 8 2013 C4YourselfExternal User Guide uge This page lets you know that your signed application information has been sent to the county office you chose and gives you an e App Number D Important Note The e App Number is import
67. IS SYMBOL EXIT THE SITE USING THE RED X IN THE UPPER RIGHT CORNER OF THE SCREEN Click the following hyperlink to be taken to the secured C4Yourself website located at https www c4yourself com c4yourself Version 12 09 May 8 2013 C4Yourself External User Guide INPORTANT NOTE Once you have goiten to the actual Application input pages Programs page and beyond the VeriSign symbol does not appear again until you are asked to sign and submit the application see picture below Home My C4Yoursel ll Help CA4Ayoursel f i Application ID Exit ss to Benetit 5 ig 7 j 9786 Application o0 Programs Please select the programs you wish to apply for You must apply for at least one program You may apply for as many programs as you wish CalFresh The CalFresh Program provides a monthly benefit for you to buy food The amount is based on your household s size income property and bills We will look at your application and review it for Expedited Service within three days Here are some reasons why you may be entitled to Expedited Service Your household s gross income and liquid resources are less than your rent mortgage and utility costs the total monthly gross income of all the people in your household is 150 or tess or you are a migrant or seasonal farm worker with less than 100 lW CalWORKs The CalWORKs program is temporary cash assistance for families with low or no income It also provides
68. The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs Please give us additional information about yourself If you can not answer a question you can skip it CW CF MC What is your preferred English language CW CF MC What is your citizenship US Citizen Status CW CF MC Are you sponsored No CW CF MC What city were you Panama City born in CW CF MC What state were you Florida ha born in CW CF MC What country were you United States born in CW CF MC Are you Hispanic or No Latino CW CF MC Please give us your race SS E 2 or ethnic origin American Indian or Alaskan Native E Black or African American E Asian If checked please select one or more of the following a Filipino L Chinese E Japanese CT Cambodian Korean L Vietnamese E Asian Indian CT Laotian _ Other Asian specify E Native Hawaiian or Other Pacific Islander If checked please select one or more of the following Native Hawaiian Guamanian Ol Samoan _ Other specify White El Unknown 8 Click Next f The Tell us more about the child page appears 9 Read the instructions and enter your information as completely as possible Version 12 09 May 8 2013 C4YourselfExternal User Guide EH Start e Application People Tell us more about this child Fill in the answers to all questions about the
69. V Joint Powers Authority Read our Privacy Statement UED Secured LELE 3 Click on the arrow next to the program you want to check The section expands and information about your benefits is displayed Version 12 09 May 8 2013 C4YourselfExternal User Guide Call Me Live Chat Home Help Cambiar idioma My Forms My Applications This page contains information related to your cases Case Number San Bernardino CalWORKs Program Status Active Benefit Amount 474 00 See Remaining Balance EBT Link Redetermination Due Month 08 2013 Reporting Type Quarterly Reporting Report Due February May August Nowember Worker Name Sharp Sam Worker Number 3645011270 Worker Phone 909 423 4631 Ifyou are eligible for CalWORKs benefits you may be eligible for Medi Cal benefits gt CalFresh gt Medical Benefits C4Yourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement LELE Version 12 09 May 8 2013 C4Yourself External User Guide My Forms Access the My Forms page oAY ourself Access to Benefits Simplified Cambiar idioma Start an application Apply for Benefits Cash Assistance Food amp Nutrition Medical wy If you have already created a C4Yourself account you My C4Yourself can log in by following the links below Access to Benef
70. Version 12 09 May 8 2013 C4Yourself External User Guide provides child support and health insurance for Bea Seymour needs help paying the bills buying food and paying medical bills A a LI Seymour Bea Yourself Yourself Tips for Using C4Yourself You can move around in the C4Yourself on line application by clicking on certain parts of the page with your mouse Below we explain of some of the ways you can e Display C4Yourself in English or Spanish e Move around in C4Yourself e Find out where you are in the application process e Enter and submit information to the county welfare department Bars Links Buttons and more The Header CAY ourself Access to Benefits Simplified The C4Yourself header is used on every page Language Selection cAY ourself Access to Benefits Simplified n You can use the Language selection on the Header to change the language on the C4Yourself pages and the language of your application documents Currently C4Yourself supports English and Spanish If you would like to complete your application in Spanish make this change before you start your application Just click the blue Cambiar idioma button and the page will be shown in Spanish Click the button again and the page changes back to English Version 12 09 May 8 2013 C4YourselfExternal User Guide om Te k CtYourselr Acceso a Beneficios Simplificado Change Language Solicitar Beneficios
71. affected area e Commercial channels for food distribution have been disrupted and those commercial channels have been restored and e The State of California has been approved to operate a D CalFresh program When the D CalFresh program is active in your County by the Federal government and the State of California a new link text appears on the C4YourselfHome page Version 12 09 May 8 2013 C4YourselfExternal User Guide ER ZC E GE a ouysel T Access to Benefits Simplified a Cambiar idioma Cash Assistance Food amp Nurbrition Medical My C4Yourself If you have already created a C4Yourself account you can log in by following the links below Access to Benefits Simplified Create an Account Check Messages Course is an online application system that View Forms Check Benefits allows you to apply for benefits This is a secured l ae Se D Se S Sa e j J J J ZE eg j mi A LEE site and all your information will be private and Wie Thangs Ta Da Open Savel Appice safe c4Yourself California Counties See a map and listing of all C4Yourself counties where you can send your application View information about your existing case s through your C4Yourself account Click here to log in it 1 or C4yYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement Am Eligible The Am I Eligib
72. ant information you should keep because you may need it if you contact the county for any reason 10 To print this page oliok ron 11 To see a summary of all the information you entered click View Summary J The Print button on the Your Information summary page will print all the information you entered as well as the Rights Responsibilities and Other Important Information It is recommended that you keep a copy for your records 12 Click Exit Jon the top of the page You will see the following message e Home Help Cay out sel F ome Access to Benefits Simplified English Cambiar idioma Exit Your application has been saved to your username C4yYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement a Se KAF Secured Click the X in the upper right hand corner of the screen The C4Yourself on line e Application Eles Home Help CAY ourself Access to Benefits Simplified closes Ww Favorites My C4Yourself Exit Exit Your application has been saved to your username C4Yourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement Version 12 09 May 8 2013 C4Yourself External User Guide What else will having a C4Yourself Account will do for Me
73. ant to upload this helps the County identify the document in C IV Enter your First Name Last Name then click Version 12 09 May 8 2013 C4YourselfExternal User Guide ER Home My C4Yourself Help CAY ourself Access to Benefits Simplified Please provide information so that we can link your document to the appropriate case submitted electronically will become part of the user s case file Submission of any inappropriate material is strictly prohibited Inappropriate material includes but is not limited to the following viruses or malicious code content that is commercial pornographic contains nudity threatening violent discriminatory or unlawful copyrighted material used without permission of the owner content or code which attempts to gather the personal information of other users phishing Submission of unlawful material will be referred to the appropriate authorities Document Information Send Documents Link Document To E Application E App Number ClV 12 275 008497 Document Type Other Correspondence First Name Seymour Last Name Yourself 5 When you Click _ Browse the computer will look for documents on YOUR computer You may need to look for the specific document you want to upload 6 Pick the document you want to upload by clicking on it The name of the document will appear in the File Name field Click Version 12 09 May 8 2013 C4Yourself
74. are from any county and or state Child Spousal Support Supplement Security Income State Supplementary Program SSI SSP Version 12 09 May 8 2013 IRT or Income Reporting Threshold Liquid Resources Minor Consent Services Version 12 09 C4YourselfExternal User Guide Meaning Cash Assistance Program for Immigrants e Unemployment Insurance Benefits UIB e State Disability Insurance SDI Workers Compensation or other disability payments e Veterans Benefits VA Strike funds Payments from Roomers and or Boarders e School grants and loans Interest on bank accounts Cash Gifts and or Winnings and other cash payments Under the rules for CalWORKs you are required to report only certain changes in your income or family circumstances between mandatory Status Reports One such report is required when your family s total income exceeds the Income Reporting Threshold IRT The IRT is the greater of 130 percent of the Federal Poverty Level FPL of the number of persons whose needs are included in the determination of the cash aid amount or the level at which the AU becomes financially ineligible The County will tell you more about the IRT and you family s IRT amount Liquid Resources means any money other than income such as Cash on hand Un cashed checks Money in bank credit union accounts Saving certificates Under the California Family Code certain lim
75. are was received and select Yes to show that you want to get Medi Cal for that month Start 1 Application People Job Income Expenses Medical Treatment You told us that there are people in your home who received medical pregnancy treatment in the past three months Please select anyone that paid and then fill in their information You can select more than one person P Next 1 Click Next J to see a Summary of the Child Care information you ve entered Start l l Application People Jo ome Expenses Medical Treatment Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Bea Yourself months Did anyone else in the home receive medical pregnancy treatment in the past three ER PL To the question Did anyone else in the home receive medical pregnancy treatment in the past three months click Yes J Version 12 09 May 8 2013 C4YourselfExternal User Guide e 3 Repeat this process for each month the person received medical care Start A p Application People Income Expenses i l Es Medical Treatment Who else in your home has received medical pregnancy treatment in the past three months You can only select one person at a time E L Seymour Bea Yourself Yourself Months of care 3 prior June months Med
76. arents the program offers a convenient method of providing a nutritionally balanced lunch at the lowest possible price Women Infants and Children Program WIC WIC is a federally funded health and nutrition program for women infants and children WIC helps families by providing checks for buying healthy supplemental foods from WIC authorized vendors nutrition education and help finding healthcare and other community services Expedited CalFresh We will look at your application and review it for Expedited Service within 3 days Here are some reasons why you may be able to get Expedited Service The total monthly income of all the people in your home is 150 or less The total resources with all the people in your home is 100 or less The examples of this money are cash with you in your bank account savings and resources For more details on the Expedited Service in CalFresh click the Help button on this page You are a migrant or seasonal farm worker without money or resources If the county finds that you are eligible to Expedited Service we will need to contact you Please check your information below Name Seymour Yourself Home Address 1 NIRVANA LANE SPACE 12 UTOPIA CA 92335 Contact Number 909 555 9999 ext You can click the next button to go to the next page of the application P Next 2 Click Next The Your Application is ready for submission page appears Version 12 09 May 8 2013
77. ation and Progress Bars have changed to show the progress you ve made through the application_orecess Start Application People ormation about the people living i your home Is anyone else in your home No Click or No depending on your situation If you click cc the Information about the people living in your home page appears If you click No J the Job Information page appears Since our sample family is a mother and child we ll follow the Yes path and add information about the child 3 Read the instructions and enter your information as completely as possible Start Application Information about the people living in your home Fil in the answers to al questions about the benefits you are asking for The CW is for CalWORKs CF es for CalFresh and MC is for Medica benefits You wii need to answer these Questons d you have appbed for those programs You must answer Questions marked with CW CF MC First Pare Bea CcCw Cr mMc Micidle Narre tow CW CEF MC Last Name ge Cww ZCT ZC What ts the bving situation of this person Cw Cr MmMc How are you related to this person Temporary Cuz of the Home Parem Biological Adoptie CF Do you buy and prepare food with this person L Notice we said Bea is Temporarily Out of the Home We chose this because in our sample family Bea is visiting her dad for a few weeks This lets the county know that Bea lives w
78. ave to re register with your county 5 Click Next Your case will be deregistered 6 Follow the Register with My County to create a new C4Yourself User Account Inter County Transfer Example 2 You have a C4Yourself User Account that is linked to your active C IV case You move from one C IV county to another and want to continue to use C4Yourself to check your benefits report changes etc When you contact the first county to report the move the county will start the inter county transfer ICT process to have the responsibility for your aid transfer to the new county This process includes getting a new C IV case number in the new county Version 12 09 May 8 2013 C4YourselfExternal User Guide an Because your C4Yourself User Account is linked to the case number in the first county you will need to deregister with the first county and register with the second 7 Follow the Deregister with My County process for the first county 8 Follow the Register with My County process to create a C4Yourself User Account and link it to your new C IV case number in the new county My Applications Start a New Application The Start New Application link text is just another way of getting to the starting point for an application This way of starting a new application is often used by customers who are already have a C4Yourself account are getting some kind of aid and want to apply for another kind of aid 1 Click Start Ne
79. cation process State and or Federal laws and regulations require the county to ask these questions During the interview the Case Manager will need to see certain documents Even if you don t have all the documents be sure to go to your interview anyway the county may help you get the documents or tell you another way to show proof of your information Checklist of things you will need to provide Type of Proof Needed Proof you can use Identification You will need to prove who you are You can use a birth certificate driver s license school or work identification voter registration Social Security card a sworn statement from someone who knows you or an identification form from General Assistance or General Relief Residence You will need to give proof that you live in California You can use your driver s license vehicle registration voter registration card proof your children are registered in school in California or that you work in California lf you have no address be prepared to tell the county where you are staying Social Security You will need to provide Social Security numbers SSN for everyone in your household who has one If someone doesn t have an SSN you will need to give proof that he she or you have applied for one You do not have to provide SSNs for people who are not applying because of their immigrant status Version 12 09 May 8 2013 C4Yourself External User Guide Type o
80. ccount Policy Address of Bank Does anyone have any other property Version 12 09 Checking Account 53 00 Yensid Bank OOo000000012 Burial Funeral Arrangements Burial Trusts Plots or Burial space 400 00 0 00 Employee Deferred Compensation 1 500 00 0 00 National OQOO000000135 Cash Uncashed Check 100 00 Mortgages Deeds 89 000 00 98 000 00 BofA OO000000001 May 8 2013 C4YourselfExternal User Guide gg 13 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Other Property page with the information you entered so you can change it Clicking takes you back to a blank Other Property page so you can start over with this page 14 If you have more property information to add click Yes and repeat the process for each piece or type of property 15 Click Ne P Next f if the information is complete The Income from Property page appears Income from Property Here is an example of how the answers to questions set up the pages we see Because we said Yes to the question about expecting to get income from Property Interest on Checking Account the Income from Property page appears 1 Read the instructions and enter your information as completely as possible Start Application People o com Expenses Property Income from Property You told us that there are people in your home expecting
81. ddress Trust Fund Edit Address Checking 5 Edit Address Account Savings Account Edit Address Certificate of Edit Address Deposit Stocks Bonds Edit Address Other Liquid Edit Address Property Oil Mining or Edit Address Mineral Rights Burial Funeral 400 Edit Address Arrangements Burial Trusts Flots or Burial Space IRA or Keogh Edit Address Plans Employee 1500 Edit Address Deferred Compensation H nbinbinnbnbinft af Life Insurance or Edit Address Annuity Life Estate Edit Address Interest In Any Property 12 Click to see a summary of the Other Property information vou ve entered Version 12 09 May 8 2013 C4Yourself External User Guide Start Application People Other Property Property Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Type of Property Current Value Amount owed if any Name of Bank dee Account Policy Address of Bank Type of Property Current Value Amount owed if any Name of Bank Account Policy Address of Bank Type of Property Current Value Amount owed if any Name of Bank Account Policy Address of Bank Type of Property Current Value Amount owed if any Name of Bank Account Policy Address of Bank Type of Property Current Value Amount owed if any Name of Bank A
82. e asked to answer this question to recover your PIN and username Your answer mine Make sure your answer is easy for you to remember me Version 12 09 May 8 2013 C4Yourself External User Guide 6 Following the instructions on the page create an eSign User Name and eSign PIN You will use these two items to sign your application electronically and any future documents you complete in C4Yourself Make sure they are easy to remember They are case sensitive 7 Click Next J The E Signature page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide C yourself Access to Benefits Simplified Start Aoi tion Other E Signature Read all the information below wery carefully VWrhen you are done select your name and enter your esigqgn Username and eSigqn PIN at the bottom to indicate you agree all the information that you Pprowided in the application is accurate You can still change information on your application now howewer once you click Submit Your Application button below this will submit your application and wou won t be able to make any further changes I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained in this statement of facts is true correct and complete Certification e I understand the questions on this form I understand that any facts that I hawe Oliver including
83. e confirmation with the U S Citizenship and Immigration Services USCIS formerly INS of the immigration status only of those persons seeking CalFresh benefits Federal law says the USCIS cannot use the information for anything else except cases of fraud I understand information including benefit and income facts that I have given on this form is subject to investigation and review by county state and federal personnel and that if I give incorrect facts my benefits may be denied or stopped I understand that I must apply for and keep any available health coverage if no cost is involved if I do not my Medi Cal will be denied or stopped I understand that I or other family members will be required to repay any cash aid I should not have received I understand I have the right to be treated equally without regard to race color national origin religion political affiliation marital status sex disability or age If you feel you have been discriminated against you may call toll free 1 866 741 6241 or for the hearing impaired TDD 1 800 688 4486 I understand that any CalFresh household adult member even if they move out the sponsor of a noncitizen household member or the authorized representative of residents in an eligible institution may be required to repay any benefits the household should not have received I understand that my case may be selected for additional review to ensure that my eligibility was cor
84. e dete servicests ayed or discontinued ype of Verification Name identity For Person yourself Seymour F Due Date 09 25 2012 RE nl Type of Verification Name ident Suse Dea JUE Date 99 01 2012 See EE Type of Verification Liquid Resource For Person yourself rF Due Date 00 21 2012 eng EE Type of Verification Date of Birth For Person yourself Seymour F Due Date 09 21 2012 Description our benefits or Status Due Date Viewable 09 19 2012 Status Due Date Status Due Date pDcuments gt pload Type of Verification Country of Birth For Person Yourself Seymour F Due Date 09 21 2012 Description Type of Verification Date of Birth For Person yourself Bea M Due Date 09 21 2012 Description Type of Verification Country of Birth For Person yourself Bea M Due Date 00 21 2012 4 You can print this form if the computer you are using is connected to a printer Version 12 09 May 8 2013 C4YourselfExternal User Guide ua Upload My Documents The C4Yourself online application lets you send documents to the County This is called uploading There are two ways to upload documents You can 1 Use a C4Yourself scanner like the Blue and Red Kiosks described below 2 Use the Upload My Documents function on the My Forms page Blue C4Yourself Kiosk You can send paper documents such as verifications to your case from a computer with a scanner or a C4Yourself Kiosk
85. e than one source for each person ES Seymour Bea Yourself Yourself Survivors Select One ENEI Child Spousal support 750 00 Monthly Educational grants loans and or scholarships Per capita Select One payments Winnings such as bingo lottery prizes Select One Strike Pay Benefits Select One Sales of notes contracts trust deeds promissory notes Select One Legal or Insurance settlements court actions pending Select One Training allowances Select One E E C E C E C E a aa aa b Meals and or room Select One 2 Select the person who gets the income the type of income enter the amount and select how often you expect to get it 3 Click The next page shows a summary of the other income information you ve entered Version 12 09 May 8 2013 C4YourselfExternal User Guide ER Start Application People Income Income from Other Sources Continued Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Child Spousal support 250 00 Bea Yourself Is anyone else in the home getting or going to get money from other sources No TT 4 Review the information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Income from Other Sources page with the information you entered so you can c
86. eePFTolowing the links beloW Access to Benefits Simplified ee View Forms View Things To Do c4yYourself ts an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe Surself California Cou 3 ETS Settee SEET Sxisting case Announcements View information about your existing case s through your CAYourself account Click here to log in UK C4Yourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement i Werlsign is Fa el Shee om On the C4Yourself Home page you can 1 Read about the public assistance programs available through C4Yourself by clicking on the program type 2 Link to the Login page Each link text will take you to a specific page after you log in For instance clicking the View Forms link text will take you to the Login page and then when you log in the My Forms page appears 3 Read about the different buttons and icons used by C4Yourself and the answers to questions other users of C4Yourself have asked This is a great place to get answers to questions like Can work and still receive help Version 12 09 May 8 2013 C4Yourself External User Guide How long will it take to find out if am eligible What is the Medi Cal Program 4 Check to see if you live in a county that uses the C4Yoursel
87. elf R Access to Benefits Simplified Start Send Application People Income Expenses Property Application E Signature Read all the information below very carefully When you are done select your name and enter your eSign Username and eSign PIN at the bottom to indicate you agree all the information that you provided in the application is accurate You can still change information on your application now however once you click Submit Your Application button below this will submit your application and you won t be able to make any further changes I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained in this statement of facts is true correct and complete Certification I understand the questions on this form I understand that any facts that I have given including benefit and income facts will be matched with local state and federal records such as employers the Social Security Administration tax welfare and unemployment agencies etc and for cash aid and CalFresh records will be matched with law enforcement agencies for arrest warrants I understand that the county will send information to the U S Citizenship and Immigration Service USCIS for verification of noncitizen status and to the Social Security Administration to check work quarters information for noncitizens applying for benefits This process may includ
88. elow Access to Beneftts T LLES AE create an account Check Messages Lao surself account you can You will get the following pop up message Version 12 09 May 8 2013 C4Yourself External User Guide C AY ourself Access to Benefits Simplified Lao Apply for Benefits i a Kap AL el el AL Es AL n erLang 1 7 C4Yourself Windows Internet Exp all x C4 Y ourself R Access to Benefits Simplified FY you wish to complete application in a language other than English or Spanish we will direct you to a PDF form which you ca print fill out and mail to your local office Proceed to the state websitefor close this window to go back to C4Yourself Access C4yYourself allows you i site and all Four T atic safe CcC4Yourself California Counties See a map and listing of all C4Yourself counties where you can send your application Announcements View information about your existing case s through your C4Yourself account Click here to log in Il ex eng After clicking the Proceed to the state website link text you will be redirected to the California Department of Social Services CDSS website and to a listing of state forms available in the language you selected Because not all of the application forms are available in all languages you may also call your county to get assistance Version 12 09 May 8 2013 C4YourselfExternal User Guide oa 4 http www dss cahwnet
89. emember Second secret ti Which phone number do you remember most from your childhood EA question Select another secret question for which you know the answer If you forget your password you will be asked to answer this question to recover your password Your answer Mine Make sure your answer is easy for you to remember Click the Next button to create the User Name and the Password Cc4yvourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement The User Name and Password are case sensitive Make sure your User Name Password and secret questions amp answers are easy for you to remember Version 12 09 May 8 2013 C4Yourself External User Guide eae Call Me Live Chat Home Help Crt ourse Lf D n 7 E My Messages My Things To ee vk My Fonms d My Applications oawlications Applications for Renewal Recertification You have no renewals to submit Applications Missing Information There are no applications missing any information Prewious Applications You have no previous applications C4 Yourself is ar istered trademark of California Statewide Automated Welfare S tem SAWS Consortium IV Joint Powers eg yE Authority Read our Privacy Statement OED You can think of the My Applications page as your personal C4Yourself Home page Notice there is a new Navigation
90. ension plans for benefits renew recertify your eee Income banene ee ee an a Households have to meet income tests unless all members are new application and get your receiving TANF or in some places general assistance Most households must meet both the gross and net income tests but a household with an elderly person or a person who is receiving certain types of disability payments only has to meet the net income test My C4 Y ourself Employment Requirements Ge BEN as Dees Generally able bodied adults without dependents ABAWDS a SAELE E between 18 and 50 can get CalFresh benefits for only 3 months Apt lication Form in a 36 month period if they do not work or participate in a Family Planning Brochure workfare or employment and training program other than job search This requirement is waived in some locations With some exceptions able bodied adults between 16 and 60 must register for work accept suitable employment and take 2 Click the Am I Eligible link text 3 Enter the required information and click Home Help CAY ourself 3 Access to Benefits Simplified Cambiar idioma Am I Eligible This page will help you to check if you might be eligible for the CalFresh Program You must answer questions marked with What is your ZIP code How many people in your home are applying for CalFresh Program How much total money before taxes did all the people in your home get last month
91. ers are sicknesses of intoxication dependence Use Disorder abuse and withdrawal caused by various substances both legal and illegal These substances include Alcohol Amphetamines Caffeine Inhalants Nicotine Prescription medications Opioids such as morphine or heroin Marijuana Cocaine Hallucinogens Phencyclidine PCP You Anyone Throughout the C4Yourself on line e Application or this Guide the words Everyone You Anyone and or Everyone mean any and all people who live in your home Version 12 09 May 8 2013 ao C4Yourself External User Guide Public Assistance Programs The table below explains the public assistance programs that are listed in the C4Yourself on line e Application For more information about any of these programs you can contact your county s Social Services Agency Program Program Name Program Description Acronym AAP Adoption The Adoption Assistance Program is available to Assistance encourage the adoption of special needs children and Program remove the financial burden of adoption APS Adult Protective Each County has an Adult Protective Services agency to Services help adults age 65 and older and dependent adults 18 64 who are disabled when these adults are unable to meet their own need or are victims of abuse neglect or exploitation County APS agencies investigate reports of abuse of elders and dependent adults who live in private homes and hotel
92. ersion 12 09 May 8 2013 C4YourselfExternal User Guide gg Additional Services The Additional Services page gathers information about your need for a referral to other services such as health screenings and or dental care for family members under the age of 21 special nutritional needs for pregnant or nursing mothers and infants family planning services and transportation to medical dental services 1 Read the instructions and provide your answers to the questions Start Application eoplh Expenses Property Additional Services The following services are available Your answers to these questions will not affect your eligibility Regular check ups to help protect your family s health are available upon request through the Child Health and Disability Prevention Program CHDP for eligible members of your family under the age of 21 Do you want more information about CHDP services Do you want CHDP medical services Do you want CHDP dental services Do you need help making medical appointments with CHDP services Do you need help making dental appointments with CHDP services Do you need help with transportation to CHDP medical services Do you need help with transportation to CHDP dental services Do you want more information about immunization services If you are pregnant you can get help finding a doctor getting healthy foods and other help Do you want to talk to someone about this help Are you breastfeedi
93. explanations that should help you understand what you are seeing but not every step is pictured The pages that you see and the questions you will be asked depend on the types of public assistance you are asking for and the information you enter The Table of Contents provides a link to the subject Place your mouse pointer over a subject in the Table of Contents then use the CTRL key on your keyboard and click on the subject with your mouse and you will be moved to the correct page Sample Case information Through this Guide we will use a made up family of a mother and her young daughter They live in a made up town in San Bernardino County All information used in this Guide is made up to help show you what the pages will look like when you move through the application The flow of the pages you see will depend on your family situation and your answers to the questions asked For instance if you say you have a motor vehicle the Motor Vehicle page will automatically come up as you go through the Property section of the application If you say no one in your household has been in the military or is the spouse parent or child of a person who served in the military the Military Service page will not automatically come up Sample Family Mom Seymour Yourself is a Navy veteran who works part time has some health insurance is buying a home has a car and utility expenses etc Bea s father is absent from the family but he
94. f If you have already created a C4Yourself account you can log in by following the links below Access to Benefits Simplified ent Check Messages Check Benefits zs A gS TO Do Open Saved Applications C4yYourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe See your remaining EBT balance C4Yourself California Counties you can send your application Contact the Coun about your existing case Announcements View information about your existing case s through your C4Yourself account Click here to log in IO aa og ag C4yYourself Is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Priva Statement SG disse veers 14 Log in with your User Name and Password 15 The My Forms page appears Notice that there is a document listed under Status Report Also see the Status is Editable and there is a Due Date dh Important Information It is important that you get your Status Report to the County by the Due Date or your benefits may be delayed changed or stopped Because our sample family Seymour Yourself and her daughter applied for CalWORKs and CalFresh they will send in a status report every quarter The form to do this is called a Quarterly Fligibility Status Report or QR 7 Version 12 09 May 8
95. f Tribal TANF Veterans Administration payments such as Disability Education Aid and Attendance Social Security Benefits or SSI SSP Railroad Retirement Board Disability or Retirement Other pension or disability Retirement Loan gifts contribution Workers Compensation Military Allotment CW CF MC Is anyone getting or going to get money from any of these sources This includes children Survivors Child Spousal support Educational grants loans and or scholarships per capita payments Winnings such as bingo lottery prizes Strike Pay Benefits Sales of notes contracts trust deeds promissory notes Legal or Insurance settlements court actions pending Training allowances Meals and or room CW CF MC Has anyone applied for or received unemployment or disability insurance benefits in the last 12 months CW CF MC Does anyone get housing or rent utilities food or clothing free or in exchange for work CW CF MC Does anyone expect a change in the amount of money they get P Next Version 12 09 May 8 2013 en C4Yourself External User Guide 1 Read the instructions and enter your information as completely as possible Start Application People ob Income Income from Other Sources Continued You told us that someone in your home gets or might get money from some the sources listed below Please select the people and fill in the information below You can only select one person but you can select mor
96. f External User Guide Program Report Type Reporting Requirement 20 hours a week or 80 hours a month The county will tell you if are considered ABAWD Voluntary Reporting Information You may report changes to the county anytime you think the change might make your Cash Aid or CalFresh to go up For example e Your income stops or goes down e Someone who has income moves out of your home e Some moves into your home and has no income e The birth of a child e Someone becomes pregnant e For CalFresh someone in your household who is disabled or age 60 or older may report new medical expense Asking for your Benefits to be Stopped You can ask the county to stop your benefits by checking the box next to the aid type Then sign and date the form and send it to your case manager STATO OF CALUFORMA HEALTA AND HUMAN E HARCES G CaLIEENIKEE EHMERG or SNE SIRVE ES QuaRTERLY Evigigiuiry STATUS REPORT Foa Gasx An Ano Cal FRESH PLEASE SIGN THE FORM AFTER Sept SR ember 1ST AND RETURN IT BY THE 5TH OF THE MONTH you need help call your worker Worker Name reer PAST ASS NAL PERT 0 172 SIN BERNATOINO CA 3545011770 a eee ER Worker Phone Humber a tient Seymour Yourse San Bemardino CA 92415 515 Case Number K Please Stop My Benefits For Cash Aid CalFresh Medi Cal at the end of this month Sign and date the last page Retum the famm to your worker You can reapply at any
97. f Proof Needed Proof you can use If you have income you will need to prove how much income you have where it comes from and when you get it For money you earn from a job you can use the following Current pay stub e Letter from employer on company letterhead W 2 Form Wage tax Receipt Most recent State or Federal Tax return Self Employment bookkeeping records Bring a copy of your benefit check or an official letter describing what you get and when you get it Liquid Resources If you have any kind of bank or credit union account you will need to prove the current balance You can you a bankbook or latest bank statement Your expenses may be considered when the county figures the amount of CalFresh benefits you might get To have your expenses considered you will need to give proof of them Bring rent or mortgage receipts utilities bills receipts for child or adult care proof of court ordered child support paid You can also bring proof of medical expenses in the 3 months before you apply if you want those expenses covered by Medi Cal Version 12 09 May 8 2013 C4YourselfExternal User Guide EEN About this Guide The purpose of the C4Yourself External User Guide is to be an easy to use tutorial and reference source for any person using the C4Yourself on line e Application This Guide provides many pictures of the pages you may see as you move through the application with
98. f on line application by clicking the See a map and listing of all C4Yourself counties link text The California Counties page shows a map of California o KB CAY ourself Access to Benefits Simplified California Counties Current C4Y ourself Counties Alpine Del Norte Inyo Napa Alameda Amador El Dorado Kern Nevada Contra Costa Butte Glenn Kings Plumas Fresno Calaveras Humboldt Lake Riverside Los Angeles Colusa Imperial Lassen San Benito Orange Madera San Bernardino Placer Marin San Joaquin Sacramento Mariposa Shasta San Diego Mendocino Sierra San Francisco Merced Siskiyou San Luis Obispo Modoc Stanislaus Mono Sutter Monterey Tehama Santa Clara Trinity Tuolumne Yuba Legend E Current C4Yourself Counties W Non C4Yourself Counties C4yYourself TZ is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement eg Bit If you live in a Non C4Yourself county you can click the name of your county to be taken to the e benefits California website http www benefitscal com Version 12 09 May 8 2013 C4YourselfExternal User Guide om English Espano Welcome to the e benefits California website BR This site connects you to applications for Medi Cal County Medical Services Program CMSP CalFresh formerly known as Food Stamps and California Work Opportunity X and Responsibility to Kids CalWORKs benefits in Calif
99. formation Clicking takes you back to the Utility Costs page with the information you entered so you can change it Clicking takes you back to an empty Utility Costs page so you can start over with this page 4 lf you have more utility cost information to add click KO and repeat the process for each person in your household that pay utility costs 5 Click co or Next f if the information is complete The Property Information page appears Property Information The Property Information page has several questions about personal property such as a house bank accounts legal or accident settlements trust funds stocks amp bonds burial or funeral arrangements retirement pension life insurance cash or un cashed checks etc The Version 12 09 May 8 2013 C4YourselfExternal User Guide answers to the questions on the Property Information page sets up which pages you will need to complete next In our sample case we ll say Seymour has a car an interest bearing checking account is buying her mobile home and has an employee deferred compensation plan Bea has a small savings account set up by her grandparents 1 Read the instructions and enter your information as completely as possible Start Application People Income Expenses Property L Property Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefi
100. g takes you back to an empty Other Health Coverage page so you can start over with this page 4 lf you have more medical treatment information to add click Yes J and repeat the process for each person in your household 5 Click co or if the information is complete The Housing Costs page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide Housing Costs The Housing Cost pages gather information about your housing expenses including rent mortgage payments and property taxes and insurance when not included in the mortgage payment or other housing costs In our sample case we ll say that Seymour is purchasing her home and pays Property taxes and Insurance separately from her mortgage 1 Read the instructions and enter your information as completely as possible Start Application People Income Expenses Housing Costs You told us that someone in your home pays for housing costs Please select the people and fill in the information below You can only select one person but you can select more than one type for each person aw Seymour Bea Yourself Yourself BER Monthly House mortgage payment 50 Monthly Property Taxes if not in house payment 500 Annually Insurance if not in house payment Quarterly Other explain Select One Te 2 Click to see a Summary of the Housing Costs information you ve entered Version 12 09 May 8 2013 C4Yourself External User Guide
101. get a job The County will determine if a family must participate in Welfare to Work activities as part of getting CalWORKs Families may also volunteer to participate Version 12 09 May 8 2013 C4YourselfExternal User Guide EEN Blank Page Version 12 09 May 8 2013 C4Yourself External User Guide About the C4Yourself on line e Application C4Yourself is a website that allows you to submit applications for public assistance benefits such as cash aid food and nutrition services and medical services If you live in one of the following counties you may apply for benefits using C4Yourself C IV Counties Alpine Lassen San Benito Amador Madera San Bernardino Butte Marin San Joaquin Calaveras Mariposa Shasta Del Norte Mendocino Sierra El Dorado Merced Siskiyou Glenn Modoc Stanislaus Humboldt Mono Sutter Imperial Monterey Tehama Inyo Napa Trinity Kern Nevada Tuolumne Kings Plumas Yuba Lake Riverside The C4Yourself on line e Application does not determine eligibility to benefits or issue benefits It is a way for you to give the county the information it will need to determine if you are eligible and how much assistance you can get A representative of the county a Case Manager will look at all the information you give to see if you are eligible The more information you can give in the e Application the better After your application is approved you can also complete annual renewals of your applica
102. gnant Has anyone been in the U S Military service or is a spouse parent or child of a person who has been in the military service Does anyone have a medical condition or emotional problem which makes it difficult to work or take care of their needs Is there anyone who can get health care coverage from an employer or absent parent but has not yet applied for coverage Is anyone getting In Home Supportive Services IHSS Does the household want to apply for a special need payment for housing or essential housing items Does the household want additional services like CHDP medical and dental services Do you want your application and other information from your Medi Cal case forwarded to the Healthy Families Program if your children receive a Share of aes Ww lb ws wee excess property Has anyone ever asked for or gotten aid or benefits including Medi Cal CMSP Diversion cash or non cash services 4 Click Net J The Authorization page appears KI Version 12 09 May 8 2013 Les C4Yourself External User Guide Authorization The Authorization page is used to give permission for someone else to use your EBT account to purchase food for you and your family and or at use your cash aid This person can be anyone you want just remember this person will have full access to ALL of your cash aid and or food amp nutrition benefits THE COUNTY IS NOT RESPONSIBLE FOR ANY LOST OR STOLEN BENEFITS 1 Read the ins
103. gov Lao Translations Windows Internet Explorer ial 2 Skip to Content Footer Accessibility Search E Department of This Site Calif GOV SociaLservices GUSS mse Coml CDSS Find Services Care Providers Forms Brochures Program Rules Reports Policy Planning Fi Office oftGovemor Edmund G Brown Jr 7 Lao Translations Visit his Website u Problems with downloading forms CDSS forms and publications are available Portable Document Format PDF For help with these files click here Tips for Usil PDF Files For Lao forms beginning with the following letters click below AIB CIDIJEF FIGIAJIJ K LIM NJO PIJQIRIS TIUIVIWIxX Y 24 gt AD 67 2 07 Information about The Birth Mother II The Global Navigation Bar Start People Application The tabs on the Global Navigation Bar tell you what kind of questions you will be asked You don t have to answer all of the questions before you submit your application but in most cases you will have to answer them in order to get benefits The more complete your application is the faster your Case Manager will be able to process it The Progress Bar This bar tells you how close you are to finishing the application Link Text Link text is underlined and blue Clicking this text will take you to another web page This is also called a hyperlink An example of link text is shown as Food amp Nutrition on the C4Yourself Ho
104. graphic contains nudity threatening violent discriminatory or unlawful copyrighted material used without permission of the owner content or code which attempts to gather the personal information of other users phishing Submission of unlawful material will be referred to the appropriate authorities Document Information Send Documents Link Document To E Application E App Number Clv 12 275 008497 Document Type Bank Verification First Name Seymour Last Name Yourself Document EE Version 12 09 May 8 2013 C4YourselfExternal User Guide au 8 cick ESE The My Forms page will appear with the name of your document under the Upload My Documents section e d Se Call Me Live Chat Home Help CAY ourselt Call Me Live Chat Home Hele Access to Benefits Simplified My Messages My Things To Do My Benefits My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office Blank Forms Pending Verifications Status Due Date Mail in Cover Sheet Verification Request List Viewsbls os isy2012 Fax Cover Sheet Status Reports Status Due Date CMS5P Rights and Quarterly Eligibility Status Report Viewable 05 06 2012 Responsibilities CMSP Statement of Facts Status Due Date Rohte and Responsibilities You currently hawe no statement of facts documents Upload My Documents
105. hange it Clicking takes you back to an empty Income from Other Sources page so you can start over with this page 5 If you have more job information to add click Yes J and repeat the process for each type of income for each person in your household 6 Click co if the information is complete The Expense Information page appears Version 12 09 May 8 2013 C4Yourself External User Guide Expense Information The Expense Information page has several questions about your expenses such as Child or Adult care housing and utilities medical etc Your answers to the questions on the Expense Information page set up which pages you will need to complete next 1 Start Application Read the instructions and enter your information as completely as possible Income Expenses Expense Information CF CW CF MC CW CF MC CF MC CF MC CW MC CW MC CW CF MC CW MC CW CF CF Meals and room Disabled adult care All or part of your childcare costs Child Support Spousal Support Medical treatment Medical expenses such as a wheelchair etc Medicare coverage Health care services Housing costs Utility costs In home supportive services 2 Click Next J The Child Care page appears Child Care Expenses 1 Read the instructions and enter your information as completely as possible Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is f
106. he home and off your C IV case To prevent him from having access to your case information such as your new phone number email address or physical address you want to deregister your current C4Yourself User Account and create a new one 1 Click the View Things to Do link text on the C4Yourself Home page The Login page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide TER cHyours elf Access to Benefits Simplified Apply for Benefits Start an a lic a tiori Cash Assistance Food amp Nutrition Medical CSSF s YVR My C4 Yourself If wou hawe already created a C4 Yourself account you can log in by following the links below Create an Account Check Messages Check Benefits cCAyYourself is an online application system that allows wou to apply for benefits This is a secured site and all your information will be private and safe Sg S remaining EBT balance C4AYourself California Counties where wou can send your application Conta E ca ty ac iL x Stim KS AOU roe Ehe nets Social Security S54 Cost OF Living Adjustment COLA Etective December 1 2009 na zort 4 Mr 2 Log into your C4Yourself User Account the My Things to Do page appears My Messag My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application Manage My Account
107. hen it is not your regular Reporting Month Program Report Type Reporting Requirement Cash Aid Income Reporting Threshold Anytime your Assistance Unit s AU S combined gross monthly income both earned and unearned is more than the Income Reporting Threshold IRT for your AU size you must report this information to the County within ten 10 days The County will let you know what your IRT is and each time it changes Each month add all of your AU s income wages earnings or salary disability income public benefits etc If the total is more that the IRT you must tell you county Families that only have unearned income or that only get CalFresh are not required to report income except on the QR7 Cash Aid Felony Drug Anytime anyone in you AU is convicted of a drug related Conviction felony for possession use or distribution of a controlled substance s has become a fleeing felon or is in violation of a condition of probation or parole and you have not already reported it Cash Aid Address Change Anytime you have an address change you must report your CalFresh new address to your county CalFresh Drop in Work If you are an Able Bodied Adult Without Dependents Hours ABAWD CalFresh recipient you must report any time the number of hours you work or are in training drop to less than Version 12 09 May 8 2013 C4Yoursel
108. i Cal requested for these Yes months Next 4 When you are finished adding each month for each person Click to see a summary of the Medical Treatment information you ve entered Start l Application ke pr D income Expenses Medical Treatment Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Remove Bea Yourself Did anyone else in the home receive medical pregnancy treatment in the past three No months i Next Version 12 09 May 8 2013 C4Yourself External User Guide 5 Review the information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Medical Treatment page with the information you entered so you can change it Clicking takes you back to an empty Medical Treatment page so you can start over with this page 6 If you have more medical treatment information to add click Yes J and repeat the process for each person in your household and for each month that person received medical treatment 7 Click No or Next f if the information is complete The Other Health Coverage page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide Other Health Coverage The Other Health Coverage pages gather information about health care insurance or coverage that you or your fam
109. ication Cash Assistance Food amp Nutrition Medical cow E TF My C4 Yourself If you have already created a C4Yourself account you can log in b Following the links below Access to Benefits Simplified i a ee VWiew Forms Check Messages Check Benefits cCcH yYourself is an online application system that allows you to apply for benefits This its a secured site and all your information will be private and safe c4Yourself California Counties See a map and listing of all C Yourself counties where you can send your application Announcements View information about your existing case s through your C4Yourself account Click here to log in a0r1 CHtYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement TTT 2 Onthe C4Yourself Login page click the register a new account here link text Version 12 09 Home Help Login Existing User Please enter your User Name and Password in the boxes below Click on the Next button and you will go back to the application you were completing ninity Based Occ este wiion CHO User User Name If this is your first time accessing C4Yourseff please register a new CBO account here Password r r May 8 2013 C4YourselfExternal User Guide EH 3 Onthe Create User Account page enter all the information reques
110. ication for CalWORKs or GA GR will be denied Version 12 09 May 8 2013
111. iese elf TP for Benefits Cash Assistance Food amp Nutrition Medical If you have already created a PVEN account you can log in by following the links_beles My C4Yourself S Create an Account ps View Forms C 4Yourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe We See your remaining EBT balance C4Yourself California Counties SE E gt RE Announcements Social Security SSA Cost Of Living Adjustment COLA Effective December 1 2009 kk Course is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement x VWerlSign Secured uii em 2 Enter your C4Yourself User Account information 3 click EE the My Messages page appears Version 12 09 May 8 2013 C4Yourself External User Guide 7 as Call Me Live Chat Home Help W ourself e Access to Benefits Simplified English Cambiar idioma My Things To Do My Benefits My Applications Key Dates n August 2012 Message Inbox Sun Mon rue wea Thu Fri sat EEEE lb k kyr p E s e p e b ho iz ba 14 us A DI as e Appllication Received 08 22 2012 ab fes fa fes ze fe s fo C4Yourself 7 is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority f 8 E Verislan
112. ill take you back to your personal My C4Yourself Home page The Help link opens a pop up window showing information to help you understand the questions on the page Home Help Cambiar idioma Applications L What is this page for This page lists current Unsubmitted Applications as well as a link te start a New Application Important to Note Prior to clicking Submit for an application please remember to fill in your name in the Application Assistor text box tart a new ations Once an application is submitted it will not be viewable through the Community Based Organization account Only the customer who must have their own confidential log in and password for their account will be able to access Bam ie ee ii es cl el el ae ee es ol e fe us es ed Applications Time Out message If you have the C4Yourself application open but you haven t done anything for 60 minutes you will get Timed out meaning you must log back in The save application process only works if you ve gotten past the Start Application page Any information you ve entered up to and including the Start Application page will not be saved You will need to start again This is an important security measure required by Federal law to protect you VeriSign Logo This symbol on the bottom of the C4Yourself Home page ensures that all the information you enter is safely being entered on a secured website IF YOU DO NOT SEE TH
113. ily members may have available through sources like a job or an absent parent In our sample case we ll say that Seymour has health insurance through her job but she pays 100 00 per year through payroll deduction and Bea is covered by her father s employer provided health plan 1 Read the instructions and enter your information as completely as possible Start Application KA Expenses Other Health Coverage You told us that there are people in your home who pay for other health care coverage including health dental vision hospitalization or long term care Please tell us more about these people Please select anyone that pays and then fill in their information You can select more than one person P Next 2 Click to see a summary of the Other Health Coverage information you ve entered Version 12 09 May 8 2013 C4Yourself External User Guide Start Application People J Income Expenses i Other Health Coverage Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button How Ofter 100 00 Annually Seymour Yourself 0 00 Annually 3 Review the information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Other Health Coverage page with the information you entered so you can change it Clickin
114. ine 1 123 Pacific Street Address Line 2 ib San Bernardina state aliformnia zip Code 92404 p County oan Bernardino K Version 12 09 May 8 2013 116 C4Yourself External User Guide 9 Click Next the Select an Office page appears My Messages S My Benefits My Forms My Applications Select an Office CG YUCCA VALLEY TAD ESP CHILD CARE PID 203537 PIMA TRL YUCCA VALLEY CA 92284 877 410 8829 e VICTORVILLE TAD ESP CHILD CARE PID 15010 PALMDALE RD VICTORVILLE CA 92392 2546 877 410 8829 COLTON TAD ESP CHILD CARE FC PID 2040 WOODPINE AVE COLTON CA 92324 1822 877 410 8829 F REDLANDS TAD CHILD CARE WIA PID 881 W REDLANDS BLVD REDLANDS CA 92373 8009 877 410 8829 ADELANTO TAD ESP CHILD CARE 10875 RANCHO RD ADELANTO CA 92301 FOTTRA Ain OO 10 The Office that you Case in assigned to will be selected Click Next The My Things to Do page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide My Messages My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application Manage My Account Manage My Account Profile Manage My Account Profile Ss This information will be used throughout the application for identification Deredister From My Count purposes Add Missing Application Information Manage My Forms and Status EE 11 Click the My Messages
115. ipating retailers CalWORKs recipients can use their EBT Card to purchase any item at participating retailers or make a cash withdrawal from a participating ATM You can only get your cash benefits at ATMs and point of sale devices in locations that are authorized to accept your CalFresh benefits You can see a list of ATMs where you can withdraw your cash benefits by going to the EBT client Website at www ebt ca gov or from your local county Social services Agency Gross Income means the amount of your income before any deductions such as taxes Social Security and retirement contributions overpayment collections wage garnishments or attachments etc Fraud and Perjury are crimes The law says you must sign a penalty of perjury statement on most forms to get and to keep getting cash aid nutrition services and Medi Cal 34 County CMSP If you lie about facts or on purpose do not give us all the facts or situations that affect your eligibility and aid payment levels you can be charged with fraud Perjury means that you lied when you swore under oath to give true correct and complete facts The Head of Household is the person you pick as the person the county will communicate with about CalFresh This is usually the person whose name will be on the Notices of Action and EBT account Income means ANY money that you get or expect to get such as Earnings including self employment and housing or utilities in exchange for work Welf
116. is approved you will get a notice telling you which people on your application are eligible to get Cash Aid A person chosen by you who can take care of your CalFresh and or Medi Cal business for you Pronounced See Four this is the abbreviation for Consortium IV Consortium IV is one of the three Statewide Automated Welfare Systems in California A CBO is a public or private nonprofit group or organization that provides humanitarian educational or spiritual assistance or support to the community DMC Services are Medi Cal s substance use disorder services Minor Consent SUD services are primarily outpatient drug free counseling services Each county welfare office chooses from a limited menu of services it can offer minors between 12 and 21 years of age A narcotic treatment program is available to youth age 18 to 21 years Pregnant or postpartum females may get SUD services that are related to health during pregnancy or the postpartum period This stands for an electronic application An e Application is one that is submitted through a computer rather than by completing a paper application An EBT card is a type of debit card that is used to issue nutrition benefits Version 12 09 May 8 2013 C4Yourself External User Guide Benefit Transfer Card Gross Income Fraud and Perjury Head of Household Income Meaning and cash aid CalFresh recipients can use their EBT Card to purchase food at partic
117. is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs Please give us information about yourself You must give us at least your name and address If you can not answer a question you can skip it You must answer questions marked with CW CF MC First Name CW CF MC Middle Name CW CF MC Last Name cw CF MC What is the best way Ki to contact YOL 7 CF Are you homeless Mo e CW CE MC Address Line 1 1 Nirvana Lane cw CF MC Address Line 2 Space 12 CW CF MC City Utopia CW CF MC State California CW CF MC Zip Code 927335 CW CF MC County San Bernardino Cw CF MC Contact Number 909 555 9999 CW CF MC Email oF Yourself email com MC Are you applying for No benefits on behalf of someone else J rma minon teenager and want confidential Minor Consent Services for family planning pregnancy related care mental health drug and alcohol abuse treatment counseling sexually transmitted diseases STD or sexual assault Next D IMPORTANT NOTE See the Terms and Definitions section for an explanation of Minor Consent Services Version 12 09 May 8 2013 Start Application 0 Select Address We could not verify your address Please double check what you entered below If you believe it is correct please click the circle next to it and click the next button Otherwise click back and change it User entered Address
118. ited medical services including substance use disorder SUD treatment can be provided to youths without their parent s or guardian s permission A youth may apply for service on his her own without consideration of his her parents or guardians income and resources State and Federal laws and regulation protect the privacy and identity of the youth applying for Minor Consent services This means that health care providers as well as the county are May 8 2013 C4Yourself External User Guide Postpartum Period Reapply or Reapplication Renew or Renewal Version 12 09 Meaning prohibited from contacting the parents or guardian of these youth Minor Consent services includes services related to Sexual assault Drug and alcohol abuse for children 12 years of age or older Pregnancy Family Planning Venereal diseases for children 12 years of age or older Prevention of and treatment for sexually transmitted diseases for children 12 years of age or older Mental health care for children 12 years of age or older who are in danger of the following o In danger of causing serious physical or mental harm to self or others o An alleged victim of incest or child abuse e Drug Medi Cal Minor Consent Minor Consent eligibility is for a 30 day period The minor must reapply in person at the county welfare office to continue to get more Minor Consent services Applying for Minor Consent is NOT available through C4Yourself
119. ith her Version 12 09 May 8 2013 C4YourselfExternal User Guide EH mom but is not in the home right now because she is visiting with her dad who is absent from the home 4 Click Next The next page of Tell us more page appears 5 Read the instructions and enter your information as completely as possible ES rell us more Fill in the answers to all questions about the benefits you are asking for The CW is for CalvwoORKs Cr is for CalFresh and Mc is for Medical benefits You wil need to answer these questions if you have applied for those programs Please give us additional information about this person If you can not answer a question you can skip it CW Crs Mi Is this person a male or female Female CW CRMC Maiden Name CW Crs Mc Date of Birth Yourself February 24 2010 CWy Cr Mc Social Security Number 326 CW CRMC Marital Status 32 6326 Newer Married CA PC Pic Is this person any of these You can select more than one Eldeny 60 and older EO without money for food Disabled Blind Pregnant Migrant Seasonal Farmworker 6 Click Next J The Background Information page appears 7 Read the instructions and enter your information as completely as possible Version 12 09 May 8 2013 C4Yourself External User Guide mmm en pen mer 0 Background Information Fill in the answers to all questions about the benefit s you are asking for
120. its Simplified C4Yourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe See your remaining EBT balance C4Yourself California Counties See a map and listing of all C4Yourself counties 1 Questions and answers where you can send your application Announcements C4yYourself earns the 2010 NASCIO award for Digital Government Government to Citizen G to C ul 20r4 1 Click the View Forms link text on the C4Yourself Home page The Login Page appears 2 Log into your C4Yourself User Account the My Forms page appears This page lets you e Open blank forms that you can complete using the computer then print and send to the County via a FAX drop off upload or through the mail e See which Verifications you need to give to the County e See the status of the Status Reports you have submitted or when your next Status Report is due e See the Statement of Facts e Upload documents Version 12 09 May 8 2013 C4YourselfExternal User Guide 429 Mail in Cover Sheet You can print a cover sheet to include with documents that you want to mail to the county This will help make sure you have the correct mailing information 1 Click the Mail in Cover Sheet link text The Please select a county page appears My Things To Do My Benefits My Applications My Forms Listed below are forms that you may print
121. ld 1 Read the instructions and enter your information as completely as possible Version 12 09 May 8 2013 C4YourselfExternal User Guide oe Start Application People Income Expenses Property Motor Vehicle You told us that someone has use of or has their name on the registration of a motor vehicle Please tell us more about this person You can only select one person at a time Seymour Bea Yourself Yourself License Number Estimated Value Balance Owed Licensed How do you use the vehicle Next 2 Click to see a Summary of the Motor Vehicle information you ve entered Version 12 09 May 8 2013 oe C4Yourself External User Guide Start Application People Motor Vehicle Income Expenses Property Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Make Model License Number Estimated Value Balance Owed Licensed Seymour Yourself a Toyota Edit Corolla C44HELP 5500 3000 Yes How do you use the vehicle Personal Does anyone else have use of or have their name on the registration of a motor EC vehicle Te 3 Review the summary information As with other summary pages you can edit or remove incorrect information Clicking takes you back to the Motor Vehicle page with the information you entered so
122. le page helps you find out if you MIGHT be eligible based on minimal information Currently Am I Eligible is used for Food amp Nutrition programs only 1 Click the Food amp Nutrition link text on the C4Yourself Home page Version 12 09 May 8 2013 C4Yourself External User Guide rc pl Home CAY 0Ursel m Access to Benefits Simplified English Cambiar idioma Food and Nutrition The Food and Nutrition Service FNS administers the nutrition assistance programs of the U S Department of Agriculture The CalFresh Program formerly known as Food Stamps federally knovwm as the Supplemental Nutrition Assistance Program SNAP can add to your food budget to put healthy and nutritious food on the table The program issues monthly electronic benefits that can be used to buy most foods at many markets and food stores To get CalFresh benefits households must meet certain tests including resource and income tests Resources L Households may have 2 000 in countable resources such as a bank account or 3000 in countable resources if at least one person is age 60 or older or is disabled However certain i a resources are NOT counted such as a home and lot the z7 resources of people who receive Supplemental Security Income SSI the resources of people who receive Temporary Get Things Done Assistance for Needy Families CalWORKs formerly AFDC and You can click on links below to apply most retirement p
123. llows you to see the current amount of aid available to you 1 Onthe C4Yourself Home page click the Check Benefits link text Version 12 09 May 8 2013 C4Yourself External User Guide Apply for Benefits Start an application Cash Assistance Food amp Nutrition Medcal My C4Yourself If you have already created a C4Yourself account you can log in by following the links below Access to Benefits Simplified C4Yourself is an online application system that allows you to apply for benefits This is a secured ec and all your information will be private and safe C4Yourself California Counties m md listi f all Cay mti where you can send your application Announcements Social Security SSA Cost Of Living Adjustment COLA Effective December i 2009 It sera CY ourself T is registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Priv rement Veriton Secured j 2 Log in to your C4Yourself User Account the My Benefits page appears Call Me Live Chat Home Help CTY 0uUrse Lf Access to Benefits Simplified Cambiar idioma My Things To Do My Forms My Applications This page contains information related to your case s Case Number San Bernardino mmm C San gt CalFresh ee Medical Benefits C4Yourself 7 is a registered trademark of California Statewide Automated Welfare System SAWS Consortium I
124. look at the information you gave by clicking any of the blue links below All the information will be used to see if you are eligible The worker will look at the information before your meeting The more information the worker has the better Your Information Income Expenses Property Other wz Each of the link texts will take you back to the selected section so you can check your answers Once you ve gone to a section the link text will change from blue to purple to help you keep track of which pages you have reviewed 1 Click Next f A new Additional Services page appears with information about the National School Lunch Program NSLP and the Women Infants and Children Program WIC Depending on your situation and your answers you may also see a message about Expedited CalFresh Version 12 09 May 8 2013 Les C4Yourself External User Guide Home My C4Yourself Help CAY ourselt Exit Access to Benefits Simplified Exit Start mae erty 7 Set Application eeler Expenses Property Other Application 900 Additional Services Links National School Lunch Program NSLP The National School Lunch Program is a federally funded program that assists schools and other agencies in providing nutritious lunches to children at reasonable prices For children the National School Lunch Program provides a nutritious meal that contains one third of the recommended dietary allowance of necessary nutrients For p
125. me and address of the office you picked You can add more information such as the number of pages your name a fax number and special instructions Notice it does not have a Case Manager name or number If you have this information we suggest you add it to the special instructions area My Messages My Things To Do My Benefits My Applications Mail Cover Sheet Date Wed Sep 12 09 57 51 PDT 2012 Number Of Pages Including Cover Sheet Tor Office Name SB TAD 01 ESP CHILD CARE PID 265 E 4TH 5T SAN BERNARDINO CA 92410 Office Address E877 410 8829 From Sender Fax Number Special Instructions 5 Click 6 Attach the printed form to the documents you want to mail to or drop off at the county The process is the same to print a Fax Cover sheet View and Print Rights and Responsibilities There are two types of Rights and Responsibilities forms available in C4Yourself These are the same Rights and Responsibilities you signed when you submitted you e Application e CMSP Rights and Responsibilities CMSP 219 e Rights and Responsibilities SAWS 2A You can read and print either form from the My Forms page Version 12 09 May 8 2013 C4YourselfExternal User Guide an 1 Click the link text The Rights and Responsibilities page appears My Things To Do My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload
126. me page Version 12 09 May 8 2013 C4Yourself External User Guide Required information You ll see some questions or entry fields with a star next to them This means the information is required and you must give the information before you can go on to the next page Selection boxes Check this _ box next to the item you want to select Check this button next to the item you want to select Buttons Next The Next button takes you to the next page Back The Back button takes you to the page before the one you are on now The Exit button ends your application If you created a user name and password all your information will be saved Remove The Remove button removes the person or information from your application Edit The Edit button takes you to a person s information so you can make changes Send Application The Send Application button sends your application to the county If you click this button it will show you a list of county offices that accept e Applications in your area based on the distance from your home address You can select the office closest to your home or one close to your work if its more convenient Home Help My C4Yourself The Home My C4Yourself Help bar allows you to move to different pages Clicking the Home link will take you back to the C4Yourself Home page Version 12 09 May 8 2013 C4YourselfExternal User Guide om The My C4Yourself link w
127. n the My Forms page now shows Viewable Version 12 09 May 8 2013 C4Yourself External User Guide My Things To Do My Benefits My Applications My Forms Listed below are forms that you may print fill out and mail FAX or drop off at your local office You can also upload documents to your county office EE You have successfully signed your document Mail in Cover Sheet Pending Verifications Fax Cover Sheet Verification Request List Viewable 09 19 2012 CMSP Rights and Status Reports Status Due Date Responsibilities CMSP 219 uarterly Eligibility Status Report Viewable 09 06 2012 Rights and Responsibilities Statement of Facts SCENE Due Date SAWS 2A You currently have no statement of facts documents Register to Vote Upload My Documents You currently have no documents pending upload Select Document To view forms you must have Adobe Reader IMPORTANT NOTE DON T FORGET TO SEND YOUR VERIFICATIONS IN The next two pictures show the QR 7 Version 12 09 May 8 2013 C4YourselfExternal User Guide TER STATE OF iren HEALTA AND HUMAN ERHVWCES ooo S e CALIPCRMIR OEPARTHEHT OF OCL SEAVEEES CAUFORRA DEPARTMENT OF HEALTH CARE SERS QuaRTERLY En trekrerusg REPORT Foa CasH AD Ano CGateesnu PLEASE SIGN THE FORM AFTER_September 157 AND RETURN IT BY THE 5TH OF THE MONTH you need help call your worker Worker Name ee FIRST CLASS MAIL PERMIT NO 1272 SAN BERNARDINO CA Sen ES POSTAGE WILL
128. ng a child If YES have you given birth within the last 12 months Do you or any family members want free or low cost family planning services to help plan how to prevent unplanned pregnancies and or have the next child If YES call your health care plan or regular doctor Or for facts and the location of confidential family planning clinics call toll free 1 800 942 1054 Next HAW Oe 2 Click to see a Summary of your answers Version 12 09 May 8 2013 C4Yourself External User Guide Start Application People Expenses Property Additional Services The following services are available Your answers to these questions will not affect your eligibility Regular check ups to help protect your family s health are available upon request through the Child Health and Disability Prevention Program CHDP for eligible members of your family under the age of 21 Do you want more information about CHDP services Yes Do you want CHDP medical services Ve Edit Do you want CHDP dental services Do you need help making medical appointments with CHDP services Do you need help making dental appointments with CHDP services Do you need help with transportation to CHDP medical services Do you need help with transportation to CHDP dental services Do you want more information about immunization services If you are pregnant you can get help finding a doctor getting healthy foods and other help Do you want to talk
129. nk text in the blue column on the left side of the page you will see a short explanation on the right side self Call Me Live Chat Home Help CAY Our Access to Benefits Simplified English Le Cambiar idioma My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application Manage My Account s x Manage My Account Profile This information wil be used throughout the application for identification purposes Manage My Forms and Status Reports Report My Changes C4yYourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Priva Statement WerlsSian Secured TEE EE TEEN Version 12 09 May 8 2013 C4YourselfExternal User Guide au Manage My Account Manager My Account Profile EIER At this time the county selection only controls the links that appear for the Call Me and Live Chat functions 1 Click the Update your profile information link text The Manage My Account Profile page appears My Benefits My Forms My Applications Manage My Account Profile You can update your profile information if something has changed If nothing has changed click the Back button You must answer questions marked with County san Bernardino Le Register with My County If you have an active case in C IV bu
130. nk text that you chose from the My C4Yourself section on the C4Yourself Home page CAYourselt a iA 4 a a af Access to Benetits Simplitied Start_an application Cash Assistance Food amp Nutrition Medical Gu 5 vw My C4Yourself If you have already created a C4Yourself account you can log in by following the links below s Create an Account Check Messages C4Yourself is an online application syste View Forms Check Benefits allows you to apply for benefits This is a seed site and all your information will be private and safe s View Things To Do Open Saved Applications Version 12 09 May 8 2013 C4Yourself External User Guide Create an Account Create an Account is the most common way of starting 1 Click the Create an Account link text The My Applications page appears 2 Click the button under Start a New Application cS Call Me Live Chat Home Help CA4Ayourself Access to Benefits Simplified My Messar My Things To Do My Benefits My Forms My Applications My Applications Start a New Disaster CalFresh Application Click the next button to start a new application Start a New pha won Click the next button to start a new application Applicatie Aze Renewal Recertification You have no renewals to submit Applications Missing Information There are no applications missing any information Previous Applications You have no
131. o that we can link your document to the appropriate case submitted electronically will become part of the user s case file Submission of any inappropriate material is strictly prohibited Inappropriate material includes but is not limited to the following viruses or malicious code content that is commercial pornographic contains nudity threatening violent discriminatory or unlawful copyrighted material used without permission of the owner content or code which attempts to gather the personal information of other users phishing Submission of unlawful material will be referred to the appropriate authorities Document Information Send Documents Link Document To Case e Case Number Select One le Document Type Geier One First Name Last Name Document 4 You will need to give information so the County can link your document to either your Case or your E Application If you have active Case Number select Case from the Link Document To dropdown When you select Case all Case Numbers linked to your C4Yourself login will appear in the Case Number dropdown If your e Application hasn t been approved yet you should pick E Application from the Link Document To dropdown Doing this changes the name of the next field from Case Number to E App Number Select your e Application number The Document Type field has a long list of the types of documents you may upload Select the type that best fits with the document you w
132. oa REPONN Reena eee eee ee eee EEE EEA 143 Status Reports in C4Yourself 0 0 cece ceecccseeeeceeeeceeeeeceeeseeeeeseeeseaeeeseeeeseeesseeseseusesseeeesenees 143 On Line Status Heportmg aprenian EAEE EA ENESA 143 Who Must Sign the Status Report ccccccccceececeeeeeeeeeeeeeeeeseeeeseeeeeseeeeseeessaeeeseeeeseeeeees 150 Other Reporting Requirements ccccccccsecccseeeeceeceseeeeeceseseeeeeseeseseeeesseeeeseeesseeeeseeeesseeeees 151 Voluntary Reporting Information ccccccceecceeeceeeceeeseeeceeeceeeeeeeseeseeeseeseeeseeseeeseeeseeeneeenes 152 Asking for your Benefits to be Giopped ec eeecceccccseceeceeeeceeeetseeeeseeeesseeeeseeeessaeeeseeeesseeeeas 152 Frequently Asked QUESTIONS cccccceeecccceeececeeecceceeeeeeeeeecesaeecesseeecesseeceeseaecesseeeeesseeeeesaeeeeeas 153 Deele 153 PUG CHD MING ecteat cde e aar eraeteal E E E xaeiuaterietanl E E 154 Version 12 09 May 8 2013 Blank Page Version 12 09 May 8 2013 C4YourselfExternal User Guide Terms and Definitions The table below offers meanings for some of the unusual words you may see in the C4Yourself on line e Application and or this Guide Term AU or Assistance Unit Authorized Representative CBO or Community Based Organization DMC or Drug Medi Cal Minor Consent e App or e Application EBT or Electronic Meaning The Assistance Unit is the group of people who are eligible to get Cash Aid When your Cash Ad
133. ontacted refuses to acknowledge paternity C4YourselfExternal User Guide ur Program Program Name Program Description between 19 and 64 years of age who Health Program e Are not eligible for Medi Cal or for the Children s Health Insurance Program e Are not pregnant e Are within their county s income limits e Meet county residency requirements and Acronym e Meet federal citizenship and immigration verification 8 requirements Linkages Linkages Adult Linkages is available to frail seniors and adults with Services disabilities aged 60 and older who are at risk of being placed in a skilled nursing facility or other institutional setting Linkages care managers provide case management services as well as information and assistance services that connect clients with available community resources to assist them to remain safely at home and independent in the community MC Medi Cal Medi Cal is California s Medicaid health care program This program pays for a variety of medical services for children and adults with limited income and resources Medi Cal is supported by federal and state taxes You can apply for Medi Cal benefits regardless of sex race religion color national origin sexual orientation marital status age disability or veteran status If you are found or determined eligible you can get Medi Cal as long as you continue to meet the eligibility requirements MSSP Multipu
134. or CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs In the next few pages we will ask you about the people in your home who have expenses Does anyone in your home pay for E e el E e e sl el el el e el Version 12 09 May 8 2013 C4YourselfExternal User Guide gg Sti iJ People Income Expenses Application Child Care You told us that there are people in your home who pay for or have part of their child care costs paid for Please tell us more about these people Please select anyone that pays or has someone else pay and fill in their information You can select more than one person Person yyy Money paid by you 40 00 How often Who gets care Seymour Yourself Money paid by other Money paid by you How often Who gets care Money paid by other Next 2 Click to see a summary of the Child Care information you ve entered Start on Application People Income Expenses opert Oth l D i Child Care Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Money paid by you 40 00 How often Weekly Who gets care Bea Seymour Money paid by other 0 00 Yourself Does anyone else in the home pay all or part of their child care costs Yes Version 12
135. ornia You can apply online Just pick your county of residence click on the Go button and you will be a step closer to getting the help you need benefitscal com Select your county of residence caoriacoumaes d a cal fresh This website has a drop down list of all the counties in California Select your county and click Go be taken to your county s e Application site Version 12 09 May 8 2013 C4Yourself External User Guide What Types of Assistance can I Apply for through C4Yourself To learn about each program click the program s link text on the C4Yourself Home page Cash Assistance Food amp Nutrition Medical In addition to these three major types of assistance programs that use the C4Yourself e Application system the Disaster CalFresh program may also be available Disaster CalFresh When a disaster is declared in a C IV county Disaster CalFresh is made available through the C4Yourself on line application This program is available to meet the needs of disaster victims within a 30 day period following a natural disaster such as a flood fire earthquake or any other natural disaster D CalFresh provides a month s worth of benefits on an Electronic Benefit Transfer EBT card that can be used to buy food at authorized retail stores The link to apply for D CalFresh is only turned on when all of the following actions occur e A Presidential Declaration for Individual Assistance has been declared in the
136. otective Child Protective Services is the system of intervention of Services child abuse and neglect in California The CPS goal is to keep the child in his her own home when it is safe and when the child is at risk to develop a plan as quickly as possible DIV Diversion Diversion services can help applicants who need some assistance but do not want or need to go on welfare Diversion services allow you to choose to get a lump sum cash payment or non cash services instead of going on aid You can only choose to get Diversion services at time of application for cash aid and you may be eligible for Medi Cal child care assistance and food stamps if you get Diversion services Expedited Expedited Services is not a public assistance program It is Services a CalFresh application process may let you get CalFresh benefits within 3 days of turning in your application To be eligible for Expedited Service you must be eligible for CalFresh AND have e Rent or mortgage and utility costs that are more than your liquid resources and this month s income before deductions OR Version 12 09 May 8 2013 C4YourselfExternal User Guide oa Program Program Name Program Description Acronym e No more than 100 liquid resources and less than 150 income before deductions for the month or e No more than 100 liquid resources and at least one member who is a migrant or seasonal farm worker Foster Care The Foster Ca
137. ou shortly or o The name of the Agent Case Manager assigned to Chat with you e A dialog box in which you and the Agent will type your comments 5 Enter your question or comment in the dialog box and click Send Each time you or the Agent types a comment and clicks the Send button the other person will see the Comment with the time stamp listed above the dialog box If you are familiar with Texting or Instant Messaging this is the same thing 6 Click the End button when you are finished and the Live Chat pop up will close Version 12 09 May 8 2013 C4Yourself External User Guide e My C4Yourself My Applications Windows Internet Explorer Favorites Tools Help ii My C4Yourself My E My C4Yourself X S d H S A My Messages Mv Thinas To Do My Benefits My Forms a E Customer Entry Windows Internet Explorer h xX ss to Be e http 192 168 26 235 system LiveCustomerServlet egain eglvc ES Fresh Application CAYourself cation LD start a new application Next ess to Benefit fed E Ganz Nex seymour yourself 12 28 53 PM I need moner where do I start start a new application 12 28 53 PM An agent will be with you shortly Recertification submit ormation 5 missing any information plications Version 12 09 May 8 2013 C4YourselfExternal User Guide EE My C4Yourself The page you see next when you log in will depend on the li
138. ple in your home We will need information on how much money you have and the bills you pay It is helpful if you have a pay stub and the bills you pay like rent utilities and child care You can view a list of information you may need before you start the application After you finish the application you can send it online to an office Before you can get benefits the agency may need to get proof of some of the answers you have given In some cases you will also need to talk with a worker over the phone or in person Your local agency will call you or send a letter about this It may take 15 minutes or more to finish all the questions C4Yourself is a registered trademark of California Statewide Automated Welfare System SAWS Consortium IV Joint Powers Authority Read our Privacy Statement 7 wll Werlsign Secured VERIFYE Finish Saved Incomplete Un submitted Application If you exit the C4Yourself on line e Application before you finish and submit your application you can come back to it later by selecting the Finish Saved Incomplete Unsubmitted Applications link text Version 12 09 May 8 2013 C4YourselfExternal User Guide aam Add Missing Application Information The Add Missing Application Information link text is different the Finish Saved Incomplete Unsubmitted Applications link text because this link will take you to an e Application you ve submitted and the county has decided needs more information The
139. r Sheet Status Reports Status Due Date paar grts ane ee ee rs oaroesra0n3 Geen Rlohts and Resocornsi bile You currently have no statement of facts documents SAWS 2A Upload M e Register to W l You currently have no documents pending upload Select Does To view formas you must have 12 You would need to repeat this process for each document you want to load Status Reporting CalWORKs CalFresh and Medi Cal all require most people report the current income property expense and employment information for each household member on a regular basis Depending on the kind of aid you get and your family s situation that may mean sending in a report every quarter twice a year or once a year When your application is approved you will be told what type of report you must make and which months are your required report months Status Reports in C4Yourself You can access and fill out your Status Report on line sign it electronically and submit it through your C4Yourself account or you can access the form print it complete and sign it manually and get it to the county through the mail in person or upload it using a Kiosk On Line Status Reporting 13 Select the View Forms link text on the C4Yourself Home page Version 12 09 May 8 2013 C4Yourself External User Guide C Y ourself Arenas EE Apply for Benefits Start an application Cash Assistance Food amp Nutrition Medical My C4Yoursel
140. re 7 30am 5 30pm PST Monday Friday If you are trying within the service hours and still geting this message please try after some time as all our agents might be busy or unavailable at this time s to submit ul Information Dons missing any information 1 s applications You may chose this window by clicking the Exit button Live Chat During specified hours C4Yourself offers the option of Chatting live with a Case Manager Currently this option is only available in the following counties 1 Click the Live Chat link text 2 Enter your name and full phone number numbers only including area code and an answer to How can we help you in the pop up window Version 12 09 May 8 2013 C4YourselfExternal User Guide ou 3 Click the Start Chat button egainzegls o 192 168 26 235 oysieny Livecunomerserviet T NAY auycels Welcome to Sam Bernardino Country s Live Chat To help us assist you please ences the information below and click Start Char h Application a new anpkcaton 1 denotes required Held Next Phone Number i0 Digun a new appkcation certification Hoe can we help your a ER Wt stion k Full Name Steg E oO any informatbon ons 4 A dialog box appears This box shows e Your message with your name and the time you sent your message e A response with either o An agent will be with y
141. re program provides cash payments and related Medi Cal benefits for children in out of home placements General The General Assistance or General Relief GA GR Assistance Gener Program is designed to provide relief and support to al Relief indigent adults who are not supported by their own means other public funds or assistance programs Each county s GA GR program is established and funded 100 percent by its own Board of Supervisors As the state is not involved in this program benefits payment levels and eligibility requirements will vary among each of California s 58 counties Homeless Homeless Assistance Permanent is a once in a life time Assistance Perm with a few exceptions cash benefit that may be available to help you get into a permanent housing situation or pay up to two months of past due rent to prevent eviction The amount you can get Is limited Homeless Homeless Assistance Temporary s a cash benefit that Assistance Temp may be available for up to 16 days in a row to meet temporary shelter need while you are looking for a permanent place to live You may be eligible for Homeless Assistance temporary if you e Have no place to live or have received a Pay Rent or Quit notice from your landlord Version 12 09 May 8 2013 C4Yourself External User Guide Program Program Name Program Description Acronym e Do not have more than 100 in resources e Are eligible to or appear to
142. rectly figured and that I must cooperate fully with county state or federal personnel in any investigation or review including a quality control review I understand that any member of my household who is avoiding or running from the law to avoid a felony prosecution custody or confinement after conviction or Is in violation of their parole or probation cannot get cash aid CalFresh or CMSP I understand that anyone who has been convicted since August 22 1996 of a drug related felony for possession use manufacturing sale 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 cannot receive CalFresh benefits Your SSN will be used to check identity to prevent duplicate participation and to verify eligibility and benefits The SSN will be used in computer matches to check your income and resources with records from tax welfare employment the Social Security Administration Income Eligibility Verification System IEVS and other agencies Differences may be checked out with you and with employers banks or others Making false statements or failing to report all facts or situations which affect eligibility and aid payments for Cash Aid CalFresh and Medi Cal CMSP may result in repayment of benefits and or criminal or civil action I declare under penalty of perjury under the la
143. riday except County Holidays Kern 8 am 5 pm Monday to Friday except County Holidays lf you can see one or both of the options on the C4Yourself Header the function is available in your county p Call Me Live Chat Home Hein CAY oursely Access to Benefits Simplified SS Wee i AITO Call Me To ask a Case Manager to call you back 1 Click the Call Me link text 2 Enter your name and full phone number including area code in the pop up window 3 Click the Call Me button Version 12 09 May 8 2013 C4Yourself External User Guide a r CalFresh Application C Yo Urse De to start a new application Access to Benefits Simplified tion to start a new application Welcome to San Bernardino County s Call Me interface To help us assist you Please enter your information and click Call Me denotes required field s to submit fi Information e a S ai a Pelt tie Dons missing any information Seymour Yourself Phone Number 10 Digits 4 applications 9165559999 be The pop up will change to Cc4AY ourself Access to Benefits Simplified KI Customer Entry Windows Internet Explorer De geg OO r CalFresh Application CAH Y OUurVse Ee R to start a new application Access to Benefits Simplified tion to start a new application iewal Recertification Thank you for your inquiry Our service hours a
144. rough your C4yYourself account Click here to log in Maar cAvourself is a registered trademark of California Statewide Automated Welfare System S4ws Consortium IW Joint Powers Authority Read our Privacy Statement S 5 V sss TETE 2 Click the register a new account link text Home Help CAY ourself Access to Benefits Simplified Cambiar idioma Existing User Please enter your User Name and Password in the boxes below Click on the Next button and you will go back to the application you were completing Hew Comitia D aced Cronapntzsak zesZZECOHh User User Name If this is your first time accessing C4Yourself please register a new CBO account here Password wot your Password 3 Onthe Create User Account page enter all the information requested Version 12 09 May 8 2013 C4YourselfExternal User Guide Home Help CAY ourselt aa Access to Benefits Simplified English Cambiar idioma Create User Account You must answer questions marked with County User Name Re enter Password YOuUr answer Second secret question YOur answer San Bernardino K Please select the county in which you live This selection will be associated to your account You will be able to change this later if you need to ComicNut Type in a User Name It must be between 5 and 20 letters or numbers and it should be something easy for you to remember Type in a Password I
145. rpose MSSP is a program that provides social and health care Senior Services management for frail elderly people who are eligible for Program placement in a nursing facility but who wish to remain in the community Version 12 09 May 8 2013 C4Yourself External User Guide Program Acronym PCSP SSI SSP Program Name Personal Care services Program Refugee Cash Assistance Supplemental Security Income State Supplementary Payment Welfare to Work Program Description PCSP is a Medi Cal program available to people with full scope Medi Cal who fit into one of the following categories An adult child who receives care services from a parent An adult who doesn t have a spouse to provide services or A child who doesn t have a parent to provide services Disabled people can get up to 283 hours of service per month under PCSP Needy refugees without children who are not eligible for any other cash aid may be eligible for 8 months of Refugee Cash Assistance These individuals may also be eligible to receive employment and other social services during the same 8 month period SSI is a federal cash assistance program for the needy blind disabled and aged SSP is a California program that augments SSI If you get SSI SSP you automatically get Medi Cal Benefits The Social Security Administration manages both SSI and SSP in California Welfare to Work helps family members get the skills needed to
146. s or hospitals and health clinics when the abuser is not at staff member The Licensing amp Certification program of the California Department of Health Services handles cases of abuse by a member of a hospital or health clinic County APS staff evaluates abuse cases and arranges for services such as advocacy counseling money management out of home placement or conservatorship CalWORKs California Work CalWORKs is a welfare program that gives cash aid and Opportunity and services to eligible needy California families The program Responsibility to is operated locally by all 58 California county welfare Kids department If a family has little or no cash and needs housing food utilities clothing or medical care they may Version 12 09 May 8 2013 C4YourselfExternal User Guide Program Program Name Program Description Cash Assistance Acronym be eligible to receive immediate short term help Families that apply and qualify for ongoing assistance receive money each month to help pay for housing food and other necessary expenses The amount of a family s monthly assistance payment depends on a number of factors including the number of people who are eligible and the special needs of any of those family members The income of the family is considered in calculating the amount of cash aid the family receives CAPI The Cash Assistance Program for Immigrants program is a Program for
147. s page to create a username and PIN which is unique to you or a particular person on this C4Yourself account It should be different than the C4Yourself username and password you are using This username and PIN will be asked for everytime this particular person is asked to sign a form or application in C4Yoursell You should create a username and PIN for each person who will sign applications or forms in C4Yourself Person i Seymour Yourself 04 29 1972 Kd Edit Remove move The above drop down is a list of people you have entered information for If the person you are creating an eSignature for is not listed please select Add Person User Name Seymourdt Type in a User Name It must be between 5 and 20 letters or numbers and it should be something easy for you to remember Type in a PIN It must be between 5 and 20 letters or numbers and it should be different than your username You must enter the same PIN again First secret Whatis your favorite pastime Ly question Select a secret question for which you know the answer If you forget your PIN or username you will be asked to answer this question to recover your PIN and username Your answer cooking Make sure your answer is easy for you to remember Second secret Which phone number do you remember most from your childhood Le question Select another secret question for which you know the answer If you forget your PIN or username you will b
148. s particular person is asked to sign a form or application in C4Yoursell You should create a username and PIN for each person who will sign applications or forms in C4Yourself Person Add Person down is a list of p person you are creating an eSig Person pople you have entered information for If the ture for is not listed please select Add User Name Type in a User Name It must be between 5 and 20 letters or numbers and it should be something easy for you to remember Type in a PIN It must be between 5 and 20 letters or numbers and it should be different than your username Re enter PIN We mct antar tha cama DTA sacsin 4 Select Add Person The E Signature Personal Information page appears CAY ourself Access to Benefits Simplified E Signature Personal Information You must answer questions marked with First Name Seymour Middle Name Four Last Name Yourself Is this person a male or female Male Female Date of Birth April 29 1972 Social Security Number 456 45 6456 Marital Status Divorced ls Te Version 12 09 May 8 2013 C4YourselfExternal User Guide ao 5 Enter the requested information and click Next f The Create New E Signature page appears with your name now available in the Person drop down Home Help CAY ourself Access to Benefits Simplified Create a New E Signature You may use thi
149. self on line e Application 3 Click the Print button The page will print 4 Click on the Verifications page The Let s get started page appears 5 Click The Instructions page appears These are the same instructions explained in the Tips for Using C4Yourself section of this Guide 6 Click The Programs page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide Starting an C4Yourself e Application Because our sample family of two needs cash food and medical help they will apply for CalWORKs CW CalFresh CF and Medical MC Therefore we will answer all the questions that apply to the programs we selected Remember this is a sample case used to show some of the common parts of the e Application The pages you see will depend on your family s situation and your answers The more information you can give the better Select Programs The Programs page allows you to choose which programs you want to apply for 1 Click the check box for each program you want to apply for Home My C4 ourself Help cAYourself Access to Benehts Sirnolited Programs Please select the programs you wish to apply for You must apply for at least one program You may apply for as many programs as you wish CalFresh The CalFresh Program provides a monthly benefit for you to buy food The amount is based on your household s size income property and bills We will look at your application and review it for
150. ser Guide 1 Click the Register to Vote link text A separate window will open with the Voter Registration page http www thisismyvoteca org REGISTER rR 1O VOTE 2 Click the button and follow the instructions on each page For help with this page contact the California Secretary of State s office or your county s Registrar of Voters Pending Verifications Let s say you get an email from your Case Manager saying you have a message about pending verifications in you C4Yourself account 1 Click the View Forms link text on the C4Yourself Home page Cayos elf j Apply for Benefits Start an application Cash Assistance Food amp Nutrition Medical My C4Yourself If you have already created a C4Yourself account you can log in by following the links below Access to Benefits Simplified a Create an Account Check Messages View Forms Check Benefits C4yYourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe CcC4Yourself California Counties See a map and listing of all C4Yourself counties where you can send your application Announcements View information about your existing cases through your C4Yourself account Click here to log in H 1 ora 2 Enter your User Name and Password on the Login page The My Forms page appears Version 12 09 May 8 2013 C4Yourself
151. st the amount paid below and ATTACH dennen mier KAS YES NO a 3 Dependent Care Did anyone who gets CalFresh pay for the care of a child disabled person or other dependent while working seeking work or attending school or training H EZ list the amount paid below and ATTACH UE ent Who paid O YEs O no OA T 1268 REGURED FORM SUBSTITUTES PERMITTED Page 30f4 TTT SN OR TOR 2 1AACH BAD ee bm E i I 7 mmm Version 12 09 May 8 2013 C4Yourself External User Guide YES Egemmeeg p sid below and ATTACH PROOF of pa Who paid or will c ange im i e next three months atter t FI 6 Did anyone get buy sell trade or give away any property land home cars bank accounts money E payments such as eet or casino winning le Rm em e tax refunds other lf YES list all items below and ATTACH PROOF mee TUSE JE SR Iraaeg Gave Sean Checking Account _ Onened losen same Sange Account lege Cl Ces pages 3 Has anyone moved into or out of your home or did you move in with someone else FYES oO Tee below O YES E NO DU name oi person Pt SU ars LS w SC OC COU Mea LW WE 8 Has anyone in your family been convicted of a drug related felony for possession use or distribution avoiding or running from any felony prosecution custody or confinement or in violation of probation or parole O YES L No H YES name Where con
152. sychiatric Hospital Mental Institution Reservation for Native Americans Group Living Arrangement for the Disabled Blind Hospital or Nursing Home Board and Care Home Does anyone take part in a food program Meals on Wheels Food Distribution operated by a Native American reservation Communal dining facility for elderly or disabled Other food program Have Cash Aid or CalFresh benefits been stopped for anyone because of e Work or Training Sanctions e Failure to meet Able Bodied Adult Without Dependent ABAWD Work Requirements e Intentional Program Violation or Welfare Fraud Do you want to let someone use your CalFresh This could be someone that lives in your home or someone that does not live in your home Do you want information on medical coverage Medi Cal or Healthy Families Next 2 Click Next The Other Information continued page appears Version 12 09 May 8 2013 C4Yourself External User Guide Start Application People Jo Expenses Property Other Information continued Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs In the next few pages we will ask you additional questions about the people in your home 3 Click BA Is any member of your household running from the law to avoid felony prosecution cus
153. t a person and fill in their information You can select more than one person L Seymour Yourself Work or Training Self employed Start date End date Employer name Job title Number of hours of work per month Monthly gross income before taxes Tips or commission Work or Training Self employed Start date End date Employer name Job title Number of hours of work per month Monthly gross income before taxes Tips or commission Work e Ho e January 05 2008 el Day Year First Jobs Inc Analyst 120 Month 1100 0 Select One gt Select One el Dayle Year le el Day Year ls Month Month 4 Click The next page is a summary of the job history information you ve entered Version 12 09 May 8 2013 C4Yourself External User Guide Start Application People Job and Job History Here is the summary of what you told us so far If you want to change the information for anyone click the Edit button If you want to remove the information for anyone click the Remove button Current or past employment as Work or Training Self employed i End date Seymour Start date 01 05 2008 Yourself Employer name First Jobs Inc Job title Analyst Number of hours of work per month 120 Monthly gross income before taxes 1 100 00 Tips or commission 0 00 Has anyone else in the home been working self employed or in training
154. t did not apply through C4Yourself you can use this process to register with your C IV County Once registered you can use C4Yourself to view your benefits report changes and get messages etc by linking your C4Yourself account to your active C IV case Because our sample family applied through C4Yourself they re already registered with San Bernardino County We will use a different sample case for this example Create a C4Yourself User Account 1 On the C4Yourself Home page click the Create an Account link text The C4Yourself Login page appears Version 12 09 May 8 2013 C4Yourself External User Guide at yourselt ss to Benefits Simplified Ap phy for Benefits Start an application lash Assistance Food amp Nutrition Medical Eur g F My lt 4Yourselt If you have already created a C4Yourself account you can log in by following the links below Access to Benefits Simplified EE te esis Wiewe heck Messages Forms Check Benefits wiew Things To Do Open Saved Applications Cev ourself is an online application system that allows you to apply for benefits This is a secured site and all your information will be private and safe CcAWourself California Counties where you can send your application L Or i mM CooL al Leh e i E T See vour remaining EBT balance now oe ie nes wiew mformation about your existing cases th
155. t must be between 5 and 20 letters or numbers and it should be different than your User Name You must enter the same Password again Who was your childhood hero K Select a secret question for which you know the answer If you forget your password you will be asked to answer this question to recover your password Snuffys mith Make sure your answer is easy for you to remember Which phone number do you remember most from your childhood Le Select another secret question for which you know the answer If you forget your password you will be asked to answer this question to recover your password Make sure your answer is easy for you to remember Click the Next button to create the User Name and the Password The User Name and Password are case sensitive Make sure your User Name Password and secret questions amp answers are easy for you to remember 4 Click Next the My Applications page appears 5 Click the My Things to Do tab Version 12 09 May 8 2013 C4Yourself External User Guide ec My Message My Things To Do My B efi My Forms My Applicat My Applications sart a New Application Click the next button to start a new application Applications for Renewal Recertification You have no renewals to submit Applications Missing Information There are no applications missing any information Previous Applications You have no previous applications 6 On the My Things to Do page
156. ted The County drop down will always list all the counties in California If you select a non C lV county an error message will appear at the top of the page What caused the error e Did you pick the right county but it isn t a C IV county If you do live in a non C lV county click the Go to my county application website link text The e benefits California page appears e Did you pick the wrong county To fix the error a Select the correct county b Re enter your Password twice C cic Next The My Application page appears CA youre Access to Benefits Simplified Create User Account You must answer questions marked with ounty San Bernardino Please select the county in which you live This selection will be associated to your account You will be able to change this later if you need to User Name Syourself Type in a User Name It must be between 5 and 20 letters or numbers and it should be something easy for you to remember Password eeeeeeee Type in a Password It must be between 5 and 20 letters or numbers and it should be different than your User Name Re enter Password You must enter the same Password again eer De fale EE Whatis your favorite pastime EA question Select a secret question for which you know the answer If you forget your password you will be asked to answer this question to recover your password Your answer Sleep Make sure your answer is easy for you to r
157. the work history of the people in your home Your answers to the questions on the Job Information page set up the pages you will be asked to complete next Our answers are based on our made up family Start Application i oo 0 Job Information Fill in the answers to all questions about the benefit s you are asking for The CW is for CalWORKs CF is for CalFresh and MC is for Medical benefits You will need to answer these questions if you have applied for those programs Next we will ask you some questions about the people in your home that have a job attend school or are in training CW CF MC Is anyone 14 years of age or older going to school college or in training CW CF MC Has anyone quit or not accepted work or training in the last 60 days CW CF Is anyone on strike CW CF Is anyone working planning to work in the next two months or is self employed Te 1 Read the instructions and enter your information as completely as possible 2 Click The Job and Job History page appears 3 Read the instructions and enter your information as completely as possible Version 12 09 May 8 2013 Start Application People Job and Job History C4YourselfExternal User Guide You told us that there are people in your home who have been working self employed or in training in the past 24 months or planning to work in the next two months Please tell us more about these people Selec
158. tion for benefits as well as manage your case information through the C4Yourself website Do I need to have a Computer The C4Yourself on line e Application is an internet based application so access to a computer with internet access is needed If you do not have a computer you may be able to use one at of one the following locations e A neighbor s or friend s house e A public library i C4 Yourself is a registered trademark of the Statewide Automated Welfare System Consortium IV Joint Powers Authority and may not be used or reproduced without the express written permission of the Statewide Automated Welfare System Consortium IV Joint Powers Authority Reg No 3 549 680 12 23 2008 Version 12 09 May 8 2013 C4YourselfExternal User Guide ue e A Community Based Organization e A county Social Services Agency Some counties have C4Yourself Kiosks like the one pictured below available at various locations throughout the county These kiosks include a computer a printer scanner and internet access C4Yourself Kiosk Locations County Locations Merced 215 Wardrobe Avenue Merced CA Merced George Washington Carver Center 21475 Reynolds Ave Dos Palos CA Merced San Joaquin Drug 9215 E Hwy 140 Planada CA Merced Castle Family Healthcare Center 3065 W Hospital Road Atwater CA San Bernardino 400 N Pepper Ave Colton CA San Bernardino 400 N Pepper Ave Colton CA San Bernardino 1627 E Holt Blvd Ontario CA
159. tody or confinement after conviction or is any member in violation of probation or parole Since August 22 1996 have you or anyone you are applying for been convicted of a drug related felony Have you or any member of your household Finished a drug treatment program that is recognized by the government Been part of a treatment program that is recognized by the government Enrolled in a government recognized drug treatment program Are they on a waiting list for a drug treatment program that is recognized by the government Stopped the use of any controlled substances and have evidence that they have stopped and continue answering the questions Version 12 09 May 8 2013 C4YourselfExternal User Guide gg Start Application OM Other Information continued Fill in the answers to all questions about the benefit s you are asking for The CW Is for CalWORKs CF ts for CalFresh and MC ts for Medical benefits You will need to answer these questions if you have applied for those programs People Job Income Expenses Property In the next few pages we will ask you additional questions about the people in your home Does everyone live in California Does everyone plan to stay in California permanently Does anyone own lease or maintain a home outside California Is anyone currently getting public assistance in California Is anyone planning to leave California for more than 60 days Is anyone pre
160. tructions and enter your information as completely as possible For our sample case we will use Seymour s brother Treat Myself Start Application People Income Expenses Property Authorization You told us that you would like to let someone in your home or someone outside your home use your CalFresh Please select the person Seymour Bea Yourself Yourself Someone Outside Home Name of the authorized person Treat Myself Te 2 Select Someone Outside the Home and enter the person s name 3 Click Net J The Military Service page appears Version 12 09 May 8 2013 C4YourselfExternal User Guide gt Military Service The Military Service page gathers information about the military service of the people in your home Military Service includes Air Force Army Coast Guard Marines National Guard and Navy If you or your spouse Is or was in the military you should complete this page You can also use this page to tell the county whether your child s absent parent is or was in the military 1 Read the instructions and enter your information as completely as possible Start SE Application eople Income Expenses Property Military Service You told us that someone in your home served in the U S Military or is the spouse parent or child of a person who served in the military Please select the people and fill in their information You can select more than one person Branch of Service Navy
161. ts You will need to answer these questions if you have applied for those programs In the next few pages we will ask you about the people in your home who have property CW CF MC Has anyone sold spent or given away any real or personal property such as a house bank account money from a legal or accident settlement or anything else CwY CF MC Do you or anyone in the household own property Is anyone buying property even if you don t live at that property CWY CF MC Does anyone have any of these Cash Uncashed Check Mortgages Deeds Retirement Plans Money Market Trust Fund Checking Account Savings Account Certificate of Deposit Stocks Bonds Other Liquid Property Oil Mining or Mineral Rights Burial Funeral Arrangements Burial Trusts Plots or Burial Space IRA or Keogh Plans Employee deferred Compensation Plans Life Insurance or Annuity Life Estate Interest In Any Property Does anyone get or expect to get money from any of the above resources such as interest dividends etc Does anyone own any personal property which costs at least 500 or which is now worth at least 5007 e Boats 3 wheelers off road vehicles snowmobiles mobile homes campers or trailers e Guns tools business or sporting equipment etc e Pets or livestock e Jewelry artwork antiques collections cameras musical equipment pianos guitars amplifiers etc e Do Not Include wedding and engagement rings or heirlooms Does
162. victed Date of conviction CH Have any of the following or any other changes happened to anyone in your home VES check the box es below and ATTACH PROOF L hg pre divorced separated registered See oe ee have a non Calfomia de ended a DP became pregnant had a baby or no bonger LJ Disability Became disabled or recovered from a disability or maor illness E Tiai lead ar aing eia per iria number of hours worked or in training went up or down or went out on eme ip ar rr ab status change or got a new cand form of letter Son USCIS INS 7 mm ae Pte sera or changed health dental or fe insurance benefits induding MEDICARE rene Any change in the amount of ime you care fonhave custody of your children ierg Age EN or stopped getting services eege BN Student age 6 18 stopped or started a regulary Started or stopped school college mme Ae able to Gamm costs for books school transportation etc ADDRESS CHANGE Fill in tis secton ONLY if you have moved or have a new mailing address H you are getting CalFresh You may ie asked to provide woot of your new shelter costs NEW Home Address Number Sheet Name Avenue Blvd ES Ant Mo chy Triste Zp Code Mew Phone Number Date Moved NEW Malling Address H diferent from Home Address city State Do you have housing cosis at this new address Do you have to pay heating cooling costs separate in O YESO NO Hues how much OI YESO NO F yes how much See SR FE Geescht
163. w Application the My Applications page appears My Messages My Benefits My Forms My Applications My Things To Do You can use this page to renew recertify your benefits update or finish start a new application Manage My Account e wd Start New Application Manage My Account Profile Register With My County Deregister From My County Manage My Applications Renew Recertify My Benefits Start a new application Start New Application Finish Saved Incomplete Unsubmitted Applications Add Missing Application Information See Prior Applications Manage My Forms and Status Reports Sian Statement of Facts SAWS 2 See Pending Verifications Complete Status Report Report My Changes 2 Click Version 12 09 May 8 2013 C4Yourself External User Guide My Message My Things To Do My Forms My Applications My Applications Start a New Application Click the next button to start a new app cz Applications for Renewal Recertification You have no renewals to submit Applications Missing Information E App Number E App Date CIV 12 268 008496 08 13 2012 CIV 12 256 008495 08 13 2012 Previous Applications E App Number E App Date CIV 12 226 008490 08 13 2012 3 The Let s get started page appears Home Help CH CAY ourself Access to Benefits Simplified Let s get started Here are some things to know before you start the application We will be asking you questions about you and the peo
164. ws of the United States of America and the State of California that the information contained in this statement of facts is true correct and complete Name Seymour Yourself 04 29 1972 eSign Seymour01 Username Description Name Select One eSign Username Description Name Select One eSign Description Please select your name and enter your eSign Username and eSign PIN Click the Submit Your Applicant Beneficiary Application button to send your application 4 Anew e App Number is assigned with the current date Version 12 09 eSign PIN eooo Signature Parent or Caretaker Relative Medi Cal Applicant Adult CalFresh Household Member or CalFresh Authorized Representative eSign PIN Signature Other Parent Living in the Home if applying for cash aid eSign PIN Signature of Witness to Mark Interpreter or Person Acting for Submit Your Application May 8 2013 C4YourselfExternal User Guide 125 Ka 7 7 SR T we Chat Home Help CAC ro self p Simplified English f Cambiar idioma My Messages My Things To Do My Benefits My Forms My Applications My Applications Click the next button to start a new application Applications for Renewal Recertification You have eegene Acn ations Missing Information Previous Applications E App Number E App Date CIW 12 27 5 008497 10 01 2012 CIW 127 22726 008490 08 13 2012 My Benefits The My Benefits page a

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