Form Sar 22 - Sponsor'S Statement Of Facts Income And Resources - California Health And Human Services Agency Page 2
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4STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSOR’S STATEMENT OF FACTS
INCOME AND RESOURCES
COUNTY USE ONLY
(Supplement to the SAWS 2, Application For CalFresh And Cash Aid)
CASE NAME: ______________
CASE NO:
______________
INSTRUCTIONS:
PLEASE ANSWER THE FOLLOWING QUESTIONS FOR YOURSELF
WORKER NO: _____________
AND YOUR SPOUSE (IF LIVING TOGETHER OR IF SPOUSE HAS SIGNED AN AFFIDAVIT OF SUPPORT)
AND RETURN IT TO THE NONCITIZEN IMMEDIATELY.
Noncitizen Name and Address
Proof may be needed to verify answers to the following questions. Attach proof when the form asks for it.
YOUR NAME (FIRST, MIDDLE, LAST)
TELEPHONE NUMBER
1
(
)
HOME ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS (IF DIFFERENT THAN HOME ADDRESS)
■ ■
■ ■
HAS SPONSOR’S SPOUSE SIGNED AN
YOUR SPOUSE’S NAME (IF LIVING TOGETHER OR SIGNED AN AFFIDAVIT OF
Yes
No
2
AFFIDAVIT OF SUPPORT?
SUPPORT) (FIRST, MIDDLE, LAST)
Do you or your spouse get assistance such as:
CalWORKs/TANF/cash assistance,
3
VERIFIED:
■ ■
■ ■
CalFresh/SNAP/food benefits or Supplemental Security Income (SSI)?
If Yes, complete below:
Yes
No
■ ■
Letter on File
■ ■
Verbal Communication
Case Name
Date of Birth
Type of Assistance
County
State
■ ■
Other:_______________
If both you and your spouse get Assistance and the noncitizen is not applying for CalFresh, complete only the Certification
section on Page 3 and return the form. For all others, go to Question
4
.
■ ■
■ ■
A. Have you or your spouse sponsored any other noncitizen’s entry into the United States?
4
VERIFIED:
Yes
No
If Yes, complete below using the I-864, I-864A or the I-134:
■ ■
Affidavit of Support
on File
Noncitizen Name
Noncitizen Address
Date of Admission to U.S.
■ ■
I-864
■ ■
I-864A
■ ■
I-134
B. Are any of the noncitizens listed in
receiving any type of assistance
4A
■ ■
■ ■
■ ■
Other: ______________
such as: CalWORKs, CalFresh or SSI?
Yes
No
If Yes, complete below:
Type of Assistance
Date First Applied
County
State
■ ■
Verified
■ ■
Verified
Do you or your spouse have other persons who are claimed or could be claimed
5
■ ■
IRS Form 1040 Reviewed
■ ■
■ ■
as dependents for federal income tax purposes?
Yes
No
■ ■
Other: ______________
If Yes, complete below:
Does Person
Name of Person(s)
Live With Sponsor
■ ■
■ ■
■ ■
■ ■
Claimed
Yes
No
Yes
No
■ ■
■ ■
■ ■
■ ■
Claimed
Yes
No
Yes
No
■ ■
■ ■
■ ■
■ ■
Claimed
Yes
No
Yes
No
■ ■
■ ■
■ ■
■ ■
Claimed
Yes
No
Yes
No
■ ■
■ ■
■ ■
■ ■
Claimed
Yes
No
Yes
No
SAR 22 (3/13) REQUIRED FORM – NO SUBSTITUTES PERMITTED
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