Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (Capi) Page 7
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8Important Information - Please Read Carefully
REPORTING RESPONSIBILITIES
You must tell us about any change within 10 days after the month it happens. Failure to report any change within 10
days after the end of the month in which the change occurs could result in a penalty.
CHANGES TO REPORT
WHERE YOU LIVE:
If you move.
If you (or your spouse) leave your household for a
If you leave the United States for 30 days or more.
calendar month or longer. For example, you enter a
If you are no longer a legal resident of the United
hospital or visit a relative.
States.
If you are released from a hospital, nursing home, etc.
HOW YOU LIVE:
If your marital status changes: You get married,
If someone moves into or out of your household.
If the amount of money you pay toward household
separated, divorced, or your marriage is annulled or
expenses changes.
you start living together after a separation.
The birth or death of any people with whom you live.
INCOME:
If the amount of money (or checks or any other type of
If you start or stop work.
payment) you receive from someone or someplace
If your earnings go up or down.
goes up or down.
If you start to receive money (or checks or any other
type of payment).
HELP YOU GET FROM OTHERS:
If someone stops or starts helping you.
If the amount of help (money, food, clothing, or payment
of household expenses) you receive goes up or down.
THINGS OF VALUE THAT YOU OWN:
If the value of your total resources goes over $2,000
If you sell or give any things of value away.
($3,000 if you are married and live with your spouse).
If you buy or are given anything of value.
YOU ARE BLIND OR DISABLED:
If you stop or refuse any vocational rehabilitation
If your condition improves or your doctor says you can
return to work.
services.
If you go to work.
UNMARRIED AND UNDER AGE 22:
If you are the parent of a child who receives CAPI
If the child starts or stops school.
benefits, you are to report if you or your child has a
change in income, a change in marital status, a change
in the value of anything the family owns, or if there is a
change in residence.
YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES OR YOU BECOME A CITIZEN OF
THE UNITED STATES.
I/We understand my/our reporting responsibilities and agree to cooperate.
YOUR SIGNATURE
DATE
SPOUSE’S SIGNATURE
DATE
PAGE 7 OF 8
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