Form Qr 3 - Mid-Quarter Status Report For Cash Aid And Food Stamps - 2006 - State Of California - Health And Human Services Agency Page 2
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1
2MANDATORY INFORMATION - continued
FS
Complete this section to report reduced work or training hours for Able-Bodied Adults without
Dependents (ABAWDs):
The number of hours worked or in training dropped below 20 hours a week or 80 hours a month
to ______ hours per week or ______ hours per month.
Name of person(s)________________________________________
Relationship to you _______________________________________
Explain what happened____________________________________
_______________________________________________________
Date of change __________________________________________
VOLUNTARY INFORMATION (All households/Assistance Units)
I would like to report the following information:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
CERTIFICATION
I UNDERSTAND THAT: If on purpose I do not report all facts or give wrong facts about my income, property, or family
status to get or keep getting aid or benefits, I can be legally prosecuted. And, I may be charged with committing a felony
if more than $400 in cash aid and/or food stamps is wrongly paid out.
I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained
in this report are true and correct and complete.
WHO MUST SIGN
For Cash Aid: you, your aided spouse or CA Domestic Partner and the other parent (of cash aided
BELOW:
children) if living in the home.
For Food Stamps: the head of household, household member or the household’s authorized
representative.
Signature or Mark
Date Signed
Home Phone
Contact Phone
Signature of Spouse or CA Domestic Partner or
Date Signed
Signature of Witness to Mark, interpreter or
Date Signed
other person completing form
other Parent of Cash Aided Children
QR 3 (7/06) RECOMMENDED FORM
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