Form Soc 809 - Cash Assistance Program For Immigrants (Capi) - Indigence Exception Statement

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY USE ONLY:
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
I
Initial
INDIGENCE EXCEPTION STATEMENT
I
Redetermination
NAME(S) OF CAPI APPLICANT(S) OR RECIPIENT(S)
CASE NUMBER
NAME OF PERSON MAKING STATEMENT (IF DIFFERENT)
RELATIONSHIP
I am/we are currently living with my/our sponsor(s).
I
I
I am/we are not currently living with my/our sponsor(s).
I am/we are applying for the indigence exception because:
I
I am/we are currently unable to obtain food and shelter with the support I
am/we are receiving from my/our sponsor(s) plus my/our own income and
resources, OR
I/we currently receive CAPI benefits, and without those benefits, I/we would be
I
unable to obtain both food and shelter with the support I am/we are receiving
from my/our sponsor(s) plus my/our own income and resources.
I am/we are currently receiving the following support from my/our sponsor(s).
(Enter “none” if no support is received):
AMOUNT OF
TYPE OF SUPPORT
SOURCE OF SUPPORT
SUPPORT
(CASH OR IN-KIND)
$
$
$
$

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