CalWORKs/CARE Program
Santa Monica College
Fax (310) 434-3655
Verification of Benefits
Please complete in BLACK ink.
A. Release – To be completed by Student
A.
I authorize the release of the following information to Santa Monica College.
Name (print or type) ____________________________________ Case # ____________________
Signature _____________________________________________
Date ____________________
B. Verification – To Be Completed by Caseworker or designee
PLEASE NOTE: The total number of participants listed in Section 1 below must equal the
number of participant names in Section 3. For example, 2 people in Section 1 and 2 names
who are receiving Cash Benefits in Section 3.
1.) This will verify that the above client is receiving :
TANF/CalWORKs (cash) in the amount of $ ______________, per month for _________people.
2.) The above client
(check one) ____ Is
____ Is not
classified as a single head of household.
3.) CASH benefits are issued for the following named individuals:
Names: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4.) Is the above client currently GAIN exempt? ______ Yes ______ No
If yes, date exemption ends _________________________________
C. Certification – to be signed by Caseworker or designee. OFFICIAL STAMP REQUIRED
Name ___________________________________________ File # ________________________
Signature ________________________________________ Date _________________________
Title _____________________________________________ Phone: _______________________