Form Soc 809 - Cash Assistance Program For Immigrants (Capi) - Indigence Exception Statement Page 2

Download a blank fillable Form Soc 809 - Cash Assistance Program For Immigrants (Capi) - Indigence Exception Statement in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Soc 809 - Cash Assistance Program For Immigrants (Capi) - Indigence Exception Statement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I/we understand that I/we must report any changes in the income I/we receive from
my/our sponsor (or anyone else) to my/our county worker.
I/we understand that this situation must be reported to the United States Citizenship and
Immigration Services (USCIS) in accordance with federal law.
I/we understand that anyone who knowingly lies or misrepresents the truth or arranges
for someone to knowingly lie or misrepresent the truth is committing a crime that may
be punishable under state law.
I/we certify under penalty of perjury that the statements given on this form are the truth
as I/we know it.
SIGNATURE OF RECIPIENT:
DATE:
PHONE NUMBER:
(
)
SIGNATURE OF SPOUSE:
DATE:
WITNESS, IF YOU SIGNED WITH AN “x”:
DATE:
SIGNATURE OF INTERPRETER OR PERSON COMPLETING FORM ON YOUR BEHALF:
DATE:
RELATIONSHIP TO RECIPIENT:
PHONE NUMBER:
(
)
PRIVACY NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-579, Sec.7), notice is hereby given for the
request of social security number information by this form. This personal information is
requested pursuant to the provisions of 8 U.S.C. Section 1631, the Social Security
Administration's Program Operations Manual System, Section SI 00502.280H, and
CDSS All-County Letter 02-63. Disclosure of the requested personal information is
voluntary. The principal purpose of the voluntary information is to identify the applicant
and thereby facilitate the processing of the form. Failure to provide the requested
information may delay or prevent processing of the form.

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Soc 813 - Cash Assistance Program For Immigrants (capi) - Indigence Exception Determination Form Soc 813 - Cash Assistance Program For Immigrants (capi) - Indigence Exception Determination Legal
Form Soc 453 - Cash Assistance Program For Immigrants (capi) - Statement Of Household Expenses And Contributions Form Soc 453 - Cash Assistance Program For Immigrants (capi) - Statement Of Household Expenses And Contributions Legal
Form Soc 807a - Cash Assistance Program For Immigrants (capi) - Request For Waiver Of Overpayment Recovery - Without Fault Form Soc 807a - Cash Assistance Program For Immigrants (capi) - Request For Waiver Of Overpayment Recovery - Without Fault Legal
Form Soc 807 - Cash Assistance Program For Immigrants (capi) - Request For Waiver Of Overpayment Recovery - Income/expenses Form Soc 807 - Cash Assistance Program For Immigrants (capi) - Request For Waiver Of Overpayment Recovery - Income/expenses Legal
Form Soc 822 - Cash Assistance Program For Immigrants (capi) - Notification Of Inter-county Transfer Form Soc 822 - Cash Assistance Program For Immigrants (capi) - Notification Of Inter-county Transfer Legal
Form Soc 452a - Cash Assistance Program For Immigrants (capi) - Income Eligibility - Child Form Soc 452a - Cash Assistance Program For Immigrants (capi) - Income Eligibility - Child Legal
Form Soc 452 - Cash Assistance Program For Immigrants (capi) Income Eligibility - Adult Form Soc 452 - Cash Assistance Program For Immigrants (capi) Income Eligibility - Adult Legal
Form Soc 454 - Cash Assistance Program For Immigrants (capi) Sponsor To Alien Deeming Worksheet Form Soc 454 - Cash Assistance Program For Immigrants (capi) Sponsor To Alien Deeming Worksheet Legal
Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (capi) Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (capi) Legal
Form Na 692 - Notice Of Change - Cash Assistance Program For Immigrants (capi) Form Na 692 - Notice Of Change - Cash Assistance Program For Immigrants (capi) Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2