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CalFresh Intake Form

Photo of mural with recipients getting food.

CalFresh Intake Form

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CalFresh is a nutrition assistance program which helps individuals and families purchase healthy foods. CalFresh benefits are issued on an electronic benefit transfer (EBT) card—like an ATM card. You can use your EBT card at most grocery stores, neighborhood stores and farmers’ markets.

Chart showing how much money you can make and still receive CalFresh. A one-person household can make a gross monthly income of $2,266 and still receive CalFresh.

Please complete the following intake form so that one of our staff members can contact you and further assist you with all questions regarding CalFresh.

CalFresh Intake Form
First Name *
Last Name *
Income Source
Expense Sources
Gender
Seniors in household?
Students in household?

If you are using Internet Explorer, this form may not work. Please try opening in a different browser. If you still cannot complete the form, please call us at 707-523-7903.

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