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REQUEST FOR VERIFICATION CASE NAME: CASE NUMBER

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCASE NAME: CASE NUMBER :WORKER NAME: WORKER PHONE/FAX:DATE: REQUEST FOR VERIFICATIONCALIFORNIA DEPARTMENT OF SOCIAL SERVICESYou have asked for CalWORKs (CW) CalFresh (CF) Medi-Cal (MC)We need proof from you to see if you can get (or keep getting)cash aid or other benefits. We have listed the information weneed below. We will not deny or end your benefits as long as you try to get the proof and tell us if you are having have listed types of proof on the back of this form .

Medical Verification Proof of pregnancy from doctor or clinic, with expected due date Doctor statement or disability finding by an agency (SSA/SDI/VA, etc.) Medical verification form (CW 61) Immunization Records (for kids under age 6) Stamped shot record/Immunization card Statement that immunizations are against your beliefs

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