Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (Capi)
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8STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS
COUNTY USE ONLY
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
CASE NAME
Instructions:
CAPI is a State-funded program for non-citizens only. Please print your
answers clearly in blue or black ink. This application must be signed and dated by the applicant
and spouse (if applicable).
CASE NUMBER
If you need more space, use the "Remarks" section on page 6. Tell your worker if you need help
in getting proof or filling out this form.
WORKER
DATE RCD
Type of Application:
Couple
Individual
Child
Child with Parents
APPLICANT
a.
First Name, Middle Initial, Last Name
LINKAGE
SSN
ID
DATE OF BIRTH
SEX
SOCIAL SECURITY NUMBER
1
Aged
Male
__ __ __-__ __-__ __ __ __
Blind
Female
Disabled
b.
Did you ever use any other names (including maiden name) or other
YES
NO
Social Security Numbers?
c.
Other names and Social Security Numbers used:
d.
RESIDENCE ADDRESS (NUMBER AND STREET)
CITY
ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
ZIP CODE
(AREA CODE) HOME PHONE
(AREA CODE) WORK PHONE
(AREA CODE) MESSAGE PHONE
PERSON WITH WHOM TO LEAVE MESSAGE
e.
Do you intend to remain in California?
YES
NO
a.
Do you have any physical or mental health problems or are you
YOU
YOUR SPOUSE
2
blind? (For example: high blood pressure, heart problems,
DAPD Referral Completed
diabetes, arthritis, osteoporosis, vision problems, depression, etc.)
YES
NO
YES
NO
If yes, explain briefly:
Disabled
Sponsored Deeming
b.
Date Problem(s) Began
Describe Health Problem(s)
SSI Referral Completed
You
Your Spouse
MARITAL STATUS
Spouse
LINKAGE
SSN
ID
3
a.
Are you married?
YES
NO
Aged
(Go to #4a.)
Blind
b.
Spouse’s Name (First, Middle Initial, Last)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
Disabled
__ __ __-__ __-__ __ __ __
c.
Did your spouse ever use any other names (including maiden name) or
YES
NO
other Social Security Numbers?
d.
Other names and Social Security Numbers used by spouse:
e.
Are you and your spouse living together?
YES
NO
Spouse eligible?
Yes
No
f.
Date you began living apart:
SPOUSE’S ADDRESS:
g.
Is your spouse applying for CAPI?
YES
NO
SOC 814 (11/02)
PAGE 1 OF 8
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