Eligibility/status Report - California
Download a blank fillable Eligibility/status Report - California in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Eligibility/status Report - California with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
ELIGIBILITY/STATUS REPORT
PLEASE SIGN THE FORM AFTER _____________ 1ST AND RETURN IT BY THE 5TH OF THE MONTH.
SUBMIT MONTH
NEED HELP? CALL YOUR WORKER.
Worker Name:
Worker Phone:
:
BAR CODE
■ ■
■ ■
■ ■
Please Stop My Benefits For:
Cash Aid
Food Stamps
Medi-Cal
at the end of this month. Sign and date the last
page. Return the form to your worker. You can reapply at any time.
PART 1:
Please tell us what happened in
_________________ ______
YEAR
REPORT MONTH
■ ■
■ ■
1.
Did you or anyone get any income or money from any source this MONTH? If “YES”, list below and
YES
NO
ATTACH PROOF.
Earnings: Babysitting, interest or dividends, rental income, salary, self-employment, sick pay, tips, vacation pay, etc. Any Government
Benefits: State Disability Indemnity (SDI), Social Security, Supplemental Security Income/State Supplementary Payment (SSI/SSP), other
government disability or retirement, rental assistance, unemployment, veteran’s retirement, Worker’s Compensation (UIB), etc. Other Benefits:
Child/spousal support, insurance or legal settlements, other private disability or retirement, railroad retirement, strike benefits, etc. Other:
Cash, gifts, loans, scholarships, etc. Income In-Kind: Such as earned housing, free housing/utilities/clothing/food, etc.
Who got the
From?
$
Gross amount
$
$
$
$
income?
Date received
$
Who got the
Gross amount
$
From?
$
$
$
income?
Date received
$
$
Who got the
Gross amount
$
$
$
From?
income?
Date received
1a. Number of hours worked or in training in this MONTH:
Who worked?
Where?
Total Hours
Who worked?
Where?
Total Hours
Where?
Who trained?
Total Hours
Who trained?
Total Hours
Where?
1b. If the income or money reported above will change in the next three months after the SUBMIT MONTH, please explain and
ATTACH PROOF.
How much will you get?
Name of person
Why will it change?
Source of income or money
First Month
Second Month
Third Month
$
$
$
$
$
$
Questions 2, 3, 4, and 5 may help you get more Food Stamps
2.
Medical Costs: Did anyone who gets Food Stamps and is disabled or 60 years or older pay medical costs?
■ ■
■ ■
If “YES”, list the amount paid below and ATTACH PROOF of payment.
YES
NO
Who paid?
Who gets care?
Amount
$
3.
Dependent Care: Did anyone who gets Food Stamps pay for the care of a child, disabled person, or
other dependent while working, seeking work, or attending school or training?
■ ■
■ ■
YES
NO
If “YES”, list the amount paid below and ATTACH PROOF of payment.
Who paid?
Amount
Who gets care?
$
COUNTY USE SECTION
QR 7 (12/08) ELIGIBILITY/STATUS REPORT - QUARTERLY FOR CASH AID AND FOOD STAMPS - REQUIRED FORM - SUBSTITUTES PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Instructions For Form Sar 7 - Eligibility Status Report - Semi-annual For Cash Aid And Calfresh
Legal
Instructions For Form Qr 7 - Eligibility/status Report - Quarterly For Cash Aid And Food Stamps
Legal
Related Categories
Parent category: Business