Form Sar 22 - Sponsor'S Statement Of Facts Income And Resources - California Health And Human Services Agency Page 3
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Are you or your spouse currently employed?
COUNTY USE ONLY
Yes
No
6
If Yes, complete section below. Attach paystubs or other proof of earnings. If you or your spouse are self-
employed, list business expenses on a separate sheet of paper and attach proof of income and expenses.
Number of
How Often Paid
Check
Enter Date Viewed
Gross Pay
Commissions
Name
Name of Employer
if
(Weekly, Monthly,
Tax Dependents
(Before Deductions)
or tips
Pay Stubs
Other
Exempt
etc.)
Claimed
■ ■
Yes
$
$
■ ■
No
■ ■
Yes
$
$
■ ■
No
Do you or your spouse receive or expect to receive any other income such as:
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Social Security, Unemployment/Disability Insurance, Child/Spousal Support,
■ ■
■ ■
Yes
No
Veterans Benefits, etc?
If Yes, complete section below and attach proof of the income.
Check
Specify Verification
if
Name
Type of Income
Amount
How Often Received
and Date Reviewed:
Exempt
■ ■
Yes
$
■ ■
No
■ ■
Yes
$
■ ■
No
■ ■
■ ■
Yes
No
Will there be any changes to this income in the next six months?
If Yes, list below what change is expected. Attach any proof you may have such as: a
letter from an employer, benefit award letter, etc.
Whose income will change?
What income will change?
How and when will it change?
Do you or your spouse have any of the following resources? Check each item. If Yes, explain below.
Resource
Sponsor
Spouse
Resource
Sponsor
Spouse
Checks or Money
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■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
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Trust Funds
Yes
No
Yes
No
Yes
No
Yes
No
(At Home or Elsewhere)
Checking, Savings,
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
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Stocks, Bonds, Certificates
Yes
No
Yes
No
Yes
No
Yes
No
Credit Union Account
Notes, Mortgages, Trust Deeds,
■ ■
■ ■
■ ■
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Other (Specify below)
■ ■
■ ■
■ ■
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Yes
No
Yes
No
Yes
No
Yes
No
Sales Contracts
Account Number
Current Value
Type of Resource
Owner
Location (Home, Bank, Address, etc.)
Check if Exempt
$
■ ■
■ ■
Yes
No
$
■ ■
■ ■
$
Yes
No
Do you or your spouse own (or are you buying) any real property, such as:
■ ■
■ ■
Yes
No
a house, land, building, etc? If Yes, complete section below:
How Used?
Balance
Value
Name of
Check
Name
Type of Property
Address/Location
(Home, Rent,
if
Owed
Mortgage Co.
Exempt
etc.)
■ ■
Yes
Date Registration
$
$
■ ■
No
and
■ ■
Yes
Records Viewed
$
$
■ ■
No
1. _____________
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■ ■
Do you or your spouse own or use or are you buying any motor vehicles, such as:
Yes
No
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2. _____________
a car, truck, boat, trailer, van, camper, motorcycle, etc? If Yes, complete, section below:
Check
License Number and
Amount of current
Name
Year, Make, Model
Balance Owed
if
State of Registration
License Fee
Exempt
■ ■
Vehicle Valuation
Yes
■ ■
No
1. $ ___________
■ ■
Yes
■ ■
No
2. $ ___________
■ ■
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Do you or your spouse who receive income pay any court-ordered support?
Yes
No
12
■ ■
Verified
If Yes, enter the monthly amount $________________ Who pays? ________________
Do you or your spouse make support payments to other persons not living in your home?
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Verified
Yes
No
If Yes, complete section below:
Who Pays
To Whom Paid (Name)
Amount Paid
$
$
$
$
Do you or your spouse own or use personal property or resources such as: Jewelry,
■ ■
■ ■
Yes
No
equipment, instruments, livestock, etc.? Do not list clothing, wedding rings, rugs,
furniture, appliances, other household furnishings. If Yes, complete section below:
Name
Name of Item
Date of Purchase Purchase Price
Gift
Amount Owed
Net Market Value
■ ■
■ ■
$
Yes
No
1.
■ ■
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$
Yes
No
2.
■ ■
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$
Yes
No
3.
■ ■
■ ■
$
Yes
No
4.
Page 2 of 3
SAR 22 (3/13) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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