PUBLIC BENEFITS APPENDIX

  1. List of County Welfare Departments in California

  2. Cash Aid/CalFresh (Food Stamp) CSF 64 Form

  3. Emergency Food Assistance Program (EFAP) Certification of Eligibility – EFA-7A Form

  4. Covered California – Application for Health Insurance Instructions

  5. Medi-Cal Form 210a: “Supplement to Statement of Facts for Retroactive Coverage/Restoration”

  6. Medicare Form: “Appointment of Representative” – CMS Form 1696 (English)/ “Nombramiento de un Representante” – CMS Form 1969 (español)

  7. Social Security Administration “Appointment of Authorized Representative” – Form SSA-1696-U4

  8. Authorization to Disclose Information to the Social Security Administration - Form SSA-827

  9. Social Security Administration’s Checklist for Online Adult Disability Application

  10. Department Of Veterans Affairs “Information Regarding Apportionment Of Beneficiary's Award” – VA Form 21-0788

  11. Department of Veterans Affairs “Application for Health Benefits – VA Form 10-10EZ

  12. Department of Veterans Affairs “Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution – VA Form 21-4193

  13. Department of Defense “Review of Discharge or Dismissal” – DD Form 293

  14. Department of Defense “Application for Correction of Military Record” – DD Form 149