Form Ar 3 Mid-Year Status Report For Calworks And Calfresh
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MID-YEAR STATUS REPORT
For CalWORKs and CalFresh
RECIPIENT’S NAME:
SOCIAL SECURITY NUMBER (OPTIONAL)
CASE NUMBER (IF KNOWN):
Use this form to report mandatory or voluntary changes that have occurred since your last redetermination/recertification
(RD/RC).
If you are reporting income information, please provide proof, such as, pay stubs; copies of checks; letters from agencies, etc.
If you’re having problems getting the proof and need help, call the county.
If you are reporting changes in expenses, please provide proof, such as, receipts; canceled checks, paid invoices; etc. If
you’re having problems getting the proof and need help, call the county.
If you are reporting an address change, please provide proof of expenses such as, a copy of your new rental agreement or
lease; rent receipt for your new address; copies of utility deposits; etc.
MANDATORY INFORMATION
If you receive CalWORKs, report the information marked CW. If you receive CalFresh, report the information marked
CF. The change of address and voluntary information sections are for all households/assistance units.
CW
My combined household income is more than the limit for my household size.
In the month of ________________ , the total combined income for my household is $ _________.
CW
Someone in my household is running from the law to avoid a felony conviction; running from the law, to
avoid custody or confinement after a felony conviction; or has been found by a court to be in violation
of probation or parole.
Name of person_______________________________________
CW/CF
Someone moved into or out of my household. (Attach a separate sheet for additional persons.)
1. Did the person move
In or
Out? (check one)
2. Name (First, Middle, Last)_________________________________________________________
3. Date of Birth (mm/dd/yyyy)________________________________________________________
4. Relationship to you______________________________________________________________
5. Regularly purchase and prepare together?
Yes
No (check one)
CW/CF
I have moved, changed my phone number or have a new mailing address.
New home address _________________________________________
_________________________________________
New mailing address (if different from your home address) ___________________________________
New phone number (______)_____________________
I receive free rent at this new address.
I receive free utilities at this new address.
My rent amount is $ _________ per month.
My utilities are $_________ per month.
See other side
AR 3 (2/15) RECOMMENDED FORM
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