Form Sar 22 - Sponsor'S Statement Of Facts Income And Resources - California Health And Human Services Agency Page 4
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4CERTIFICATION
•
I understand that if on purpose I don’t give the right facts or all the facts for the CalWORKs, CalFresh or cash-based
Medi-Cal Programs, I can be punished and I can be legally accused of the crime of fraud. If I am found guilty of committing
fraud, I can be fined up to $10,000 for CalWORKs and $250,000 for CalFresh. And, I can go to jail/prison for up to 5 years for
CalWORKs and 20 years for CalFresh. In the CalWORKs and CalFresh Programs, my benefits can be stopped for
6 months, 12 months, 2 years, 4 years, 5 years, 10 years or forever.
•
I understand that the information provided on this form may be verified by local, state and federal agencies.
•
I understand that the noncitizen’s case, including my statement, may be selected for an additional review to ensure that the
noncitizen’s eligibility was determined correctly.
•
I understand that I may be required to repay any benefits which are overpaid because of incorrectly or incompletely reported
information.
•
If the noncitizen is applying for Cash Aid, both you and your spouse must sign the form. If the noncitizen is applying for CalFresh benefits
only, either you or your spouse must sign the form.
SPONSOR’S CERTIFICATION:
•
I understand that the term for Sponsorship is normally an indefinite period of time.
•
I declare under penalty of perjury under the laws of the United States of America and the State of California that the above information
contained on this statement of facts is true, correct, and complete.
SPONSOR’S SIGNATURE OR MARK
DATE
SPONSOR’S SPOUSE’S SIGNATURE OR MARK (IF LIVING WITH SPOUSE OR SPOUSE HAS SIGNED AN AFFIDAVIT OF SUPPORT)
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
•
If the noncitizen is applying for Cash Aid, the noncitizen must sign this form. If the noncitizen is applying for CalFresh only, the form must
be signed by the noncitizen, the head of household, a household member, or an authorized representative.
NONCITIZEN’S CERTIFICATION:
•
I have reviewed this signed and completed form from my sponsor(s). I declare under penalty of perjury under the laws of the United States
of America and the State of California that it is true, correct, and complete to the best of my knowledge.
NONCITIZEN’S OR DECLARANT’S SIGNATURE OR MARK
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
COUNTY USE ONLY
Evaluation of Sponsor/Sponsor’s Spouse
CalWORKs
CalFresh Sponsor/Sponsor’s Spouse/Registered Domestic
Real/Personal Property Resources
Sponsor/Sponsor’s Spouse Income Computation
Partner Computation
A.
ITEMS
VALUE
A. Earned Income
$ _______________
A. Earned Income
$ _____________
_____________________
$ _______________
_____________________
$ _______________
B. Less 20%
- _____________
B. Unearned Income
+ _______________
_____________________
$ _______________
C. Unearned Income
+ ______________
_____________________
$ _______________
C. Subtotal
= _______________
_____________________
$ _______________
D. Gross Income Deduction for
D. Total number of sponsored
B. Total
$ _______________
Sponsor’s household size
- ______________
noncitizens applying for/receiving
CW
CF
CalWORKs
_______________
E. Subtotal
= _____________
NA
$1500
C. Less: CalFresh
E. Divide C by D
= _______________
F. Total number of sponsored
Deduction ($1500)
noncitizens replace applying
for/receiving CalFresh
______________
D. Equals Subtotal
=
F. Number of sponsored noncitizens
in this AU
_______________
E. Total number of sponsored
G. Total (Divide E by F)
= ______________
noncitizens applying
G. Total (Multiply E by F)
= _______________
for/receiving CW/CF
F.Total (Divide D by E)
=
Amount in F to be included in each noncitizen’s property
Amount in G to be deemed income for each sponsored
Amount in G to be deemed income for entire AU.
limits.
noncitizen.
WORKER SIGNATURE
WORKER SUPERVISOR
DATE
SAR 22 (3/13) REQUIRED FORM - NO SUBSTITUTES PERMITTED
Page 3 of 3
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