Form Soc 813 - Cash Assistance Program For Immigrants (Capi) - Indigence Exception Determination
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
Initial Claim
I
Redetermination
I
INDIGENCE EXCEPTION DETERMINATION
County of __________________________________
NAME OF APPLICANT/RECIPIENT
DATE OF BIRTH
CASE NUMBER
DATE OF BIRTH
CASE NUMBER
NAME OF APPLICANT/RECIPIENT (SPOUSE)
NAME OF APPLICANT/RECIPIENT’S SPONSOR
NAME OF APPLICANT/RECIPIENT’S SPONSOR
SECTION A: Living Arrangements
I
I
1.
Lives with sponsor
2.
Does NOT live with sponsor
Check One:
I
I
4.
Lives independently (use Section D to describe
3.
Lives with others and pays for room and board
Check One:
I
how food and shelter is obtained)
5.
Lives with others and receives free room and board
I
6.
Homeless
If box #1 or #5 is checked, skip down to Section D. Applicant is not eligible for the indigence exception. MPP §49-037.42
SECTION B: Monthly Income
Redeterminations Only:
$ _______________________
Current monthly CAPI payment received:
All Cases:
$ _______________________
Total cash and in-kind contributions from sponsor(s)
$ _______________________
Total cash and in-kind contributions from others*
$ _______________________
Total of recipient’s/applicant’s other income (including spouse’s, if living together)
$ _______________________
Total of income from all sources
$ _______________________
Federal SSI rate
*Includes all non-CAPI public benefits (GA/GR, CalFresh, CalWORKs, etc.) MPP §49-03.441
SECTION C: Resources
Sponsor(s)’ resources available to applicant/recipient
$ _______________________
Applicant’s/recipient’s own resources (including spouse’s, if living together)
$ _______________________
Total resources available to applicant/recipient
$ _______________________
Federal SSI resource limit ($2,000 for an individual, $3,000 for a couple)
$ _______________________
SECTION D: Comments
(enter a brief narrative describing the circumstances surrounding this request)
Based on the information summarized on this form, it is determined that the indigence exception:
(check 1 box)
I
I
does
does not
apply to the applicant(s)/recipient(s) named above.
DATE
ELIGIBILITY WORKER’S SIGNATURE
DATE
SUPERVISOR’S SIGNATURE
CAPI is a public assistance program funded by the State of California. Forward a copy of this form to:
Office of Program and Regulation Development
California Department of Social Services
U.S. Citizenship and Immigration Services
Adult Programs Branch
AND
20 Massachusetts Avenue NW
744 P Street, M.S. 9-7-96
Washington, DC 20529-0001
Sacramento, CA 95814-6413
or email to: soc813@dss.ca.gov
SOC 813 (7/16)
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