Form Cf 286 Sar Calfresh Budget Worksheet/semi-Annual Reporting Households
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH BUDGET WORKSHEET/SEMI-ANNUAL REPORTING HOUSEHOLDS
CASE NAME
COMPANION CASE REFERENCE
CASE NUMBER
CLASSIFICATION
I
I
I
I
NA
PA
MIXED
TC
I
MID-CERTIFICATION PERIOD
CERTIFICATION
BUDGET IS BASED ON:
SAR 7
I
REPORT
PERIOD
FROM
THROUGH
INSTRUCTIONS:
List the amount of Reasonably Anticipated Income on line 1a. Reasonably Anticipated Income is the specified amount of
monthly income the household and CWD are reasonably certain the household will receive in the SAR payment period. Use
the worksheet under 1b to average income for those households that elect to or are required to have their income averaged.
PART 1 - GROSS INCOME
A. NONEXEMPT GROSS UNEARNED INCOME
1a. Reasonably Anticipated Income
$___________
1b. Income Averaging (use worksheet below)
SOCIAL
CHILD/SPOUSAL
SCHOLARSHIPS,
OTHER
SECURITY, UIB,
SUPPORT
GRANTS, LOANS
DIB, PENSIONS
$____________
$____________
$____________
$____________
Month 1/Year ________/________
$____________
$____________
$____________
$____________
Month 2/Year ________/________
$____________
$____________
$____________
$____________
Month 3/Year ________/________
$____________
$____________
$____________
Month 4/Year ________/________
$____________
$____________
$____________
$____________
$____________
Month 5/Year ________/________
$____________
$____________
$____________
$____________
Month 6/Year ________/________
$____________
Total Unearned Income
$____________
Averaged Gross Unearned Income (total unearned + number of month)
2. Monthly Income Amount From 1a (or 1b if appropriate)
$___________ (A2)
3. Cash Aid
$ __________ (A3)
4. Less Child Support Paid (enter any remainder in B3)
$ __________ (A4)
Total $ __________ (A5)
5. Total Gross Unearned Income (A2 + A3 - A4)
B. NONEXEMPT GROSS EARNED INCOME
1a. Reasonably Anticipated Income
$________________
1b. Income Averaging (use worksheet below)
TRAINING
GROSS
SELF EMPLOYMENT
ALLOWANCES
SALARY/WAGES
$________________
Month 1/Year ________/________
$________________
$________________
$________________
Month 2/Year ________/________
$________________
$________________
$________________
$________________
$________________
Month 3/Year ________/________
Month 4/Year ________/________
$________________
$________________
$________________
Month 5/Year ________/________
$________________
$________________
$________________
$________________
Month 6/Year ________/________
$________________
$________________
Total Gross Earned Income
$________________
$________________
Averaged Gross Earned Income (total gross earned income + number of months)
2. Monthly Income Amount From 1a (or 1b if appropriate)
$____________ (B2)
3. Less Remainder of Child Support Paid (if not fully used in Section A)
$ ___________ (B3)
Total $____________ (B4)
4. Total Gross Earned Income (B2 - B3)
PART 2 - GROSS INCOME
C. GROSS INCOME TEST FOR HOUSEHOLDS WITH NO ELDERLY OR DISABLED MEMBERS
1. Maximum Gross Income allowed for Household
$________________
Size of ______ (from table)
2. Total Gross Income (A5 + B4) =
$________________
I
I
3. Gross Income Eligible? (Is C2 less than or equal to C1?)
YES
NO
CF 286 SAR (12/15) RECOMMENDED FORM
PAGE 1 OF 2
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