Decrease in Income "*" indicates required fields Step 1 of 7 14% I have an open CalFresh (food stamps) or MediCal case:* I have a current open case in Contra Costa County I have a open case outside Contra Costa County I need to open a case with Contra Costa County Let us help you apply: Online - BenefitsCal Telephone - (866) 663-3225 Mail - Mail in an application to EMPLOYMENT AND HUMAN SERVICES CONTRA COSTA COUNTY PO BOX 4114 Concord, Ca 94524-9700 In Person or Drop off - Drop off your competed application to a local district office Fax - (925) 228-0310 Return to Help Page Please contact your current county for assistance with your case. Please visit the California Department of Heath Care Services website for county contact information Return to Help Page Consent*EHSD uses secure encryption to ensure your privacy and protect your data. You will receive a confirmation e-mail after you submit your information. Data you submit through this form will not be available on ehsd.org or any publicly accessible systems. I agree to the privacy policy. ConfirmationNumberThis field is hidden when viewing the formDate for Confirm #Hidden field used to configure date mergetag output to confirmation number MM slash DD slash YYYY CHANGE IN INCOME – My household income has DECREASED Please report a decrease for any members in your household. This could be a change of employment for earnings or a change to public benefits for unearned income.Name* First Last County Case NumberYour case number is located at the top of any Notice of Action you have received in the mail from Contra Costa County and looks like 1F12345 If you do not know your case # please provide as much info as possible.Your Date of Birth (DOB)* MM slash DD slash YYYY Do You Have a Social Security Number (SSN)?* Yes No Last 4 digits of SSNPhone*Do you have an email address?* Yes No Email Enter Email Confirm Email What is the cause for your decrease of income?* Lower wages and/or hours Quit a job Lost a job Public benefit ended or decreased (Unemployment UIB, Disability DIB, Social Security SSA/SSI, General Assistance, etc.) Other If the decrease is from a job-based source, what is the approximate number of hours worked per month?Who is having this decrease?* What is the new Gross Amount (including taxes, benefits, tips, etc.)*How often do you receive this income?*HourlyDailyWeeklyEvery Other WeekMonthlyOther Source:*(Who is causing you this decrease? Who is your employer or what is the Public Benefit?)What was the starting date for this change? MM slash DD slash YYYY I would like to upload an image to verify my change* Yes No Upload your image(s) below:There is a 2MB file size limit Drop files here or Select files Accepted file types: jpg, jpeg, tiff, tif, pdf, gif, png, doc, docx, xls, xlsx, Max. file size: 2 MB, Max. files: 3. Do you need to report an additional change?* Yes No PhoneThis field is for validation purposes and should be left unchanged.
