How to Fill Out the California GEN 853 Sworn Statement Form

The California GEN 853 form is a one-page sworn statement from the California Department of Social Services that you fill out by entering your case information at the top, writing a dated, specific account of the facts you need to verify in the middle, and signing under penalty of perjury at the bottom. County eligibility workers use it for CalFresh, CalWORKs, and Medi-Cal when you can’t produce the usual paperwork and your written declaration is the next best evidence. Signed correctly, it carries the same legal weight as court testimony under California Code of Civil Procedure Section 2015.5.

When Counties Ask for This Form

The form is stamped “Required Form – No Substitutes Permitted,” so a handwritten note on your own paper won’t do when a caseworker specifically requests a GEN 853.¹ Common situations:

Verifying household expenses like heating, cooling, or dependent care when you can’t produce a bill.
Confirming income or a recent job loss when an employer hasn’t provided pay stubs.
Establishing residency or identity when you lack a lease, utility bill, or standard ID.
Reporting food destroyed in a disaster or household misfortune so the county can issue replacement CalFresh benefits. Some counties use a separate affidavit (DFA 303) for this instead.²
Reporting zero income at initial application. Your signed statement alone is sufficient; the county cannot require more.

Where to Get a Blank Copy

Download the form from the CDSS forms library under the E–H alphabetical listing,³ or grab the PDF from BenefitsCal at benefitscal.com.¹ If you can’t print, any county social services office will hand you one at the front desk.

Filling Out the Header

The form has three zones: a header block for case identifiers, a middle block for your statement, and a signature area. A strip at the very top with Worker Name, Worker ID, and Worker Phone Number is agency-use only. Leave it blank.

Complete these fields:¹

Case Name: your full legal name as it appears on your benefits case.
Case Number: assigned by your county. Check prior correspondence or your BenefitsCal account.
Customer ID: some counties use this interchangeably with the case number. If you don’t know it, leave it and the caseworker will add it.
Name (Last, First, Middle): repeat your name in the personal information block.
Street Address, City, State, Zip Code: your current mailing address.
Home Telephone Number and Contact/Cell Phone Number: give at least one working number.

Writing the Sworn Statement

The center of the form is a blank space headed “I declare as follows:” This is where the substance goes. Treat it as a short, factual letter that says what happened, when, and why you can’t provide standard documentation.

A few things that make a statement usable:

Be specific with dates. “My refrigerator stopped working on June 3, 2026, and I lost approximately $180 in groceries” is far more useful than “I lost food recently.”
Name the missing document. If you can’t produce a pay stub, say so: “My employer, [name], has not provided wage statements for May 2026. My gross pay for that period was approximately $1,400.”
Explain the cause. For food replacement, federal rules require the statement to describe why the food was destroyed and confirm you understand the penalties for misrepresentation.²
Keep it factual. Don’t argue what you deserve. Stick to what happened and what needs verifying.

If you run out of room, write “continued on attached page,” attach a second sheet, and sign and date that sheet too.

Signing Under Penalty of Perjury

Below the statement, pre-printed language reads: “I declare under penalty of perjury that the statements made herein are true and correct to the best of my knowledge and belief. I am aware that it is unlawful to give false information.”¹ Sign and date directly below it.

The form has two signature lines. The second is for a co-signer, such as another adult in the household attesting to the same loss. If only one person is signing, leave the second line blank.

Your signature turns the written statement into the legal equivalent of sworn testimony under California law.⁴

How to Submit It

Once the form is signed and dated, use whichever route works for your situation:

Upload through BenefitsCal. Log in, open the Document Center, and click Upload. The system takes PDFs, JPGs, PNGs, and most common file types up to 8 MB per file. You can also upload without logging in from the “Need to upload a document?” section on the homepage. A clear phone photo works.⁵
Mail the original to your county social services office. Certified mail with return receipt gives you proof of delivery date.
Hand-deliver it. Most counties have secure drop boxes available during and after business hours. Ask the front desk for a date-stamped receipt.

The Deadline That Trips People Up

If you’re using the form to request replacement CalFresh benefits for destroyed food, timing is strict. Report the loss to your county within 10 days of the date the food was destroyed, and get the signed statement to the county within 10 days of that report. If the 10th day falls on a weekend or holiday, the next business day still counts as timely.² Miss either window and the county won’t issue a replacement. The replacement covers the value of what you lost, up to one month’s allotment.

What Happens After You Submit

For food replacement, federal rules require the county to issue benefits within 10 days of your report or within two working days of receiving the signed statement, whichever is later.² If the county suspects fraud, it can delay or deny.

For other uses like income, expenses, or residency, a caseworker reviews the statement and either accepts it or contacts you for clarification. Processing time varies by county and by whether the information raises questions. If the caseworker finds your statement questionable, they can ask for additional evidence even though a client statement would ordinarily suffice.

If the County Denies Your Claim

A denial comes with a written notice explaining why. You have 90 days from the date the notice was mailed to request a state hearing.⁶ File online through the CDSS appeals portal or call the toll-free hearing line at 1-800-743-8525 (TDD: 1-800-952-8349).⁷

If you file before the county actually reduces or stops your benefits, CalFresh continues at the current level until the hearing decision or the end of your certification period, whichever comes first. If you lose, you’ll have to repay any extra benefits you received during the appeal.⁷

Penalties for False Statements

Because the form is signed under penalty of perjury, intentionally lying on it exposes you to prosecution under California Welfare and Institutions Code Section 10980. Penalties scale with the amount of aid wrongfully obtained:⁸

$950 or less in fraudulent aid: misdemeanor, up to six months in county jail, a fine up to $500, or both.
More than $950: can be charged as a felony with 16 months, two years, or three years in state prison and fines up to $5,000. It can also be prosecuted as a misdemeanor with up to one year in jail and fines up to $1,000.
Filing under a false identity or creating fictitious applicants: straight felony, 16 months to three years in prison and fines up to $5,000.

The county will also seek repayment of any benefits you weren’t entitled to. The statute requires willful deception with intent to defraud, so honest mistakes on the form don’t trigger these penalties. If you notice an error after submitting, contact your caseworker and correct it in writing.

1
BenefitsCal. GEN 853 – Sworn Statement
2
eCFR. 7 CFR 274.6 – Replacement Issuances
3
California Department of Social Services. On-line Forms and Publications E – H
4
California Legislative Information. California Code CCP 2015.5
5
CalSAWS. BenefitsCal Quick Guide – Upload Documents Within an Application
6
California Department of Social Services. State Hearing Requests
7
ACMS. Public Appeal Request
8
California Legislative Information. California Code WIC 10980 – Penalties