Family benefits worksheet
A printable from Benefits and Public Charge Complete Guide. Fill it in by hand. Nothing you write is collected by this website.
Family benefits worksheet
Write each person's first name only. Do not write anyone's immigration status, Social Security number or A number on this sheet.
For each person in the home
- Name: ____________ Age: ____ Under 19? ____ Pregnant? ____
- Name: ____________ Age: ____ Under 19? ____ Pregnant? ____
- Name: ____________ Age: ____ Under 19? ____ Pregnant? ____
- Name: ____________ Age: ____ Under 19? ____ Pregnant? ____
Benefits we use now, and the date each started
- Medi-Cal: who? ________ since: ________
- CalFresh: who? ________ since: ________
- WIC: who? ________ since: ________
- CalWORKs: who? ________ since: ________
- Housing help: who? ________ since: ________
- Other: ________ since: ________
Apply or ask about
- Medi-Cal for every child and anyone pregnant
- CalFresh for any citizen children
- WIC for anyone pregnant or any child under 5
- School meals (ask the school office)
- Disability or Paid Family Leave if someone cannot work because of illness, a new baby or caring for family
- CalEITC and Young Child Tax Credit at tax time
Before we apply or cancel anything, if anyone has a green card case now or soon
- Talk with a legal helper first
From Benefits and Public Charge Complete Guide. Facts checked October 21, 2026. Free information, not legal or medical advice.