Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (Capi) Page 5
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8INCOME
COUNTY USE ONLY
a.
Have you received, or do you expect to receive income from
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YOU
YOUR SPOUSE
any of the following sources?
Source
YES
NO
YES
NO
Gifts/Support
Social Security
Veteran’s Administration (VA)
Supplemental Security Income (SSI)
Unemployment Benefits
State Disability
Workers’ Compensation
Other Pensions/Annuities
CalWORKs
General Assistance/Relief
Rental Income
Insurance Payments
Interest/Dividends
Alimony/Child Support
Verified?
Other Income
Yes
No
b.
For each “yes” answer, give the following information:
$ _________
Person Receiving
Type
Gross Amount
How Often Received
$ _________
$
$ _________
$
$ _________
$
Total: $ _________
$
YOU
YOUR SPOUSE
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a.
Do you receive or do you expect to receive any wages?
Verified?
YES
NO
YES
NO
Yes
No
b.
If yes, give the following information:
Gross Wages
Dates of
Employer’s Name, Address,
Person Working
Paid:
Employment
and Telephone Number
Amount
How Often Paid
Daily
From:
Weekly
Bi-Weekly
$
Monthly
To:
Twice Monthly
Fluctuating
From:
$
To:
YOU
YOUR SPOUSE
27
a.
Have you been, or do you expect to be self-employed in the
current year?
YES
NO
YES
NO
Tax Return?
b.
If yes, give the following information:
Yes
No
Last Year’s
This Year’s
Dates of Self-
Type of Business
Year of
Employment
Gross Income
Net Income (Loss)
Gross Income
Net Income (Loss)
Tax Return: ________
If you are under age 65 and disabled, do you have any special
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YOUR SPOUSE
expenses related to your illness or injury that are necessary for you to
IRWE?
work? If yes, describe in “Remarks” on page 6.
YES
NO
YES
NO
Yes
No
YOU
YOUR SPOUSE
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Are you currently receiving Food Stamps or have you recently applied
for Food Stamps?
YES
NO
YES
NO
PAGE 5 OF 8
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Parent category: Legal