Lancer ID Number
*
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Enter Email
Confirm Email
Phone
*
Are you currently participating in: CalWORKs/GAIN/TANF?
*
Yes
No
Number of ADULTS in the household receiving CalWORKs/TANF
*
When did your cash aid (TANF) begin?
*
Marital Status
*
Single
Separated
Married
Divorced
Are you employed?
*
Part-time
Full-time
Not employed
Type of employment
*
Campus employment
Work-Study
Other
Other type of employment
*
Are you a parent?
*
Yes
No
Child-related Questions
Have you been identified as a single parent and head of the household by your DPSS Office?
*
Yes
No
Number of CHILDREN in the household receiving CalWORKs/TANF
*
List each dependent child
Use the "+" button to add additional children
Name
Age
Date of BIrth
Type of Verification (BC/SR)
Is/are your child/children in daycare?
Yes
No
End Child-Related Questions
Attach Files
Please upload your Verification of Benefits, Child Birth Certificate or Child School Enrollment documents here.
Drop files here or
Email
This field is for validation purposes and should be left unchanged.