PUBLIC BENEFITS APPENDIX

PUBLIC BENEFITS APPENDIX

List of County Welfare Departments in California – PG. 499Cash Aid/CalFresh (Food Stamp) CSF 64 Form – PG. 501Emergency Food Assistance Program (EFAP) Certification of Eligibility – EFA-7A Form – PG. 503Covered California – Application for Health Insurance Instructions – PG. 505Medi-Cal Form 210a: “Supplement to Statement of Facts for Retroactive Coverage/Restoration” – PG. 508Medicare Form: “Appointment of Representative” – CMS Form 1696 (English)/ “Nombramiento de un Representante” – CMS Form 1969 (español) – PG. 512Social Security Administration “Appointment of Authorized Representative” – Form SSA-1696-U4 – PG. 517Authorization to Disclose Information to the Social Security Administration - Form SSA-827 – PG. 523Social Security Administration’s Checklist for Online Adult Disability Application – PG. 526Rosen Bien Galvan & Grunfeld LLP, Where to Send your SSI Application When in Custody – PG. 527.Department Of Veterans Affairs “Information Regarding Apportionment Of Beneficiary's Award” – VA Form 21-0788 – PG. 533Department of Veterans Affairs “Application for Health Benefits – VA Form 10-10EZ – PG. 536Department of Veterans Affairs “Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution – VA Form 21-4193 – PG. 541Department of Defense “Review of Discharge or Dismissal” – DD Form 293 – PG. 543Department of Defense “Application for Correction of Military Record” – DD Form 149 – PG. 548
Appendix A
List of County Welfare Departments in California

This list was adapted from the following CalFresh website: http://www.calfresh.ca.gov/PG839.htm

Alameda County 
Social Services Agency 
1-888-999-4772 

Alpine County 
Health & Human Services 
(530) 694-2235 

Amador County 
Department of Social Services 
(209) 223-6550 

Butte County 
Department of Employment & Social Services 
North County: (530) 879-3845 
South County: (530) 538-7711 

Calaveras County 
Calaveras Works & Human Services Agency 
(209) 754-6448 

Colusa County 
Department of Health & Human Services 
(530) 458-0250

Contra Costa County 
Social Services Department District Offices: 
Richmond: (510) 412-3280, (510) 231-8114 
Hercules: (510) 262-7709 
Antioch: (925) 706-4560 
Pleasant Hill: (925) 602-9379
If calling from within Contra Costa County, for general food information dial 2-1-1

Del Norte County 
Department of Health & Social Services 
(707) 464-3191

El Dorado County 
Health and Human Services Agency 
(530) 642-7300

Fresno County 
Department of Social Services 
1-877-600-1377

Glenn County 
Human Resource Agency 
(530) 934-6514 

Humboldt County 
Department of Health & Human Services 
1-877-410-8809 (CalFresh)
(707) 476-4700 (All programs) 

Imperial County 
Department of Social Services 
(760) 337-6800 

Inyo County 
Department of Health & Human Services 
(760) 872-1394

Kern County 
Department of Human Services 
(661) 631-6000, 1-877-410-8812

Kings County 
Human Services Agency 
(559) 582-3241

Lake County 
Department of Social Services 
(707) 995-4200

Lassen County 
Department of Health & Human Services 
(530) 251-8152

Los Angeles County 
Department of Public Social Services
626-569-4298, 1-877-597-4777

Madera County 
Department of Social Services 
(559) 675-2300 

Marin County 
Department of Health & Human Services 
(415) 473-3400

Mariposa County 
Department of Human Services 
(209) 966-2000

Mendocino County 
Department of Social Services 
(707) 463-7700 

Merced County 
Human Services Agency 
(209) 385-3000

Modoc County 
Department of Social Services 
(530) 233-6501 

Mono County 
Department of Social Services 
(760) 924-1770 

Monterey County 
Department of Social Services 
(831) 755-4400 

Napa County 
Health & Human Services 
(707) 253-4511

Nevada County 
Department of Social and
Child Support Services 
(530) 265-1340 

Orange County 
Social Services Agency 
(714) 541-4895

Placer County 
Health & Human Services 
(916) 784-6000, (530) 889-7610 

Plumas County 
Department of Social Services 
(530) 283-6350 

Riverside County 
Department of Public Social Services 
(951) 358-3000 

Sacramento County 
Department of Human Assistance 
(916) 874-3100 

San Benito County 
Health & Human Services 
(831) 636-4180

San Bernardino County 
Human Services System 
Transitional Assistance Department 
(909) 388-0245; (877) 410-8829

San Diego County 
Health & Human Services Agency 1-866-262-9881 
If calling from within San Diego County, 
for general food information dial 2-1-1

San Francisco County 
Food Assistance Center 
(415) 558-1001 
(877) 366-3076 

San Joaquin County 
Human Services Agency 
(209) 468-1000 

San Luis Obispo County 
Department of Social Services 
(805) 781-1600 

San Mateo County 
Human Services Agency 
1-800-223-8383

Santa Barbara County 
Department of Social Services, District Offices 
Lompoc: (805) 737-7080 
Santa Maria: (805) 346-7135 
Santa Barbara: (805) 681-4401 

Santa Clara County 
Social Services Agency 
1-877-962-3633 

Santa Cruz County 
Human Services Department 
1-888-421-8080

Shasta County 
Health and Human Services Center 
(530) 225-5767 
(530) 225-5777 recorded message 

Sierra County 
Human Services Department 
(530) 993-6722

Siskiyou County 
Welfare Department 
1-800-662-7031 

Solano County 
Health & Social Services Department 
1-800-400-6001 

Sonoma County 
Human Services Department 
(707) 565-2715, 1-877-699-6868

Stanislaus County 
Community Services Agency 
1-877-652-0734 

Sutter County 
Department of Human Services; Welfare & Social Services Division: 1-877-652-0735 

Tehama County 
Department of Social Services 
(530) 527-1911 

Trinity County 
Department of Health & Human Services 
(530) 623-1265, 1-800-851-5658

Tulare County 
Health and Human Services Agency 
1-800-540-6880 

Tuolumne County 
Department of Social Services 
(209) 533-5711 

Ventura County 
Human Services Agency 
805-477-5100; 866-904-9362

Yolo County 
Department of Employment & Social Services 
(530) 661-2750 

Yuba County 
Health & Human Services Department 
(530) 749-6311 

Appendix B
Cash Aid/CalFresh (Food Stamp) CSF 64 Form

See the next page for a copy of form CSF 64.

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

See the next page for a copy of form EFA-7A.

Appendix D
Covered California – Application for Health Insurance Instructions

NOTE: For the full Covered California/ Medi-Cal application, please go to your local county social services office, or find the full application online at:

https://www.coveredca.com/PDFs/paper-application/CA-SingleStreamApp_92MAX.pdf

See the next page for Instructions on how to apply to Covered California/Medi-Cal.

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

See the next page for a copy of MC Form 210a.

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

See the next page for a copy of CMS Form 1696 in English and español.

Appendix G
Social Security Administration “Appointment of Authorized Representative” – Form SSA-1696-U4

See the next page for a copy of Form SSA-1696-U4.

Appendix H
Authorization to Disclose Information to the Social Security Administration - Form SSA-827

See the next page for a copy of Form SSA-827.

Appendix I
Social Security Administration’s Checklist for Online Adult Disability Application
Appendix J
Where to Send Your SSI Application When in Custody

Appendix K
Department of Veterans Affairs “Information Regarding Apportionment Of Beneficiary's Award” – VA Form 21-0788

See the next page for a copy of VA Form 21-0788.

This form is also available at:

http://www.vba.va.gov/pubs/forms/VBA-21-0788-ARE.pdf

Appendix L
Department of Veterans Affairs “Application for Health Benefits” – VA Form 10-10EZ

See next page.

This form is also available at:

http://www.va.gov/vaforms/medical/pdf/vha-1010EZ-fill.pdf

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

See the next page for a copy of VA Form 21-4193. This form is also available at: http://www.reginfo.gov/public/do/DownloadDocument?documentID=203887&version=1

Appendix N
Department of Defense “Review of Discharge or Dismissal” – DD Form 293

See next page for a copy of DD Form 293.

This form is also available at: http://www.dtic.mil/whs/directives/forms/eforms/dd0293.pdf

Appendix O
Department of Defense “Application for Correction of Military Record” – DD Form 149

See the next page for a copy of DD Form 149.

This form is also available at:

http://www.public.navy.mil/asnmra/corb/NDRB/Documents/dd0149.pdf