Form Soc 807 - Cash Assistance Program For Immigrants (Capi) - Request For Waiver Of Overpayment Recovery - Income/expenses

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
REQUEST FOR WAIVER OF OVERPAYMENT RECOVERY - INCOME/EXPENSES
NAME OF OVERPAID PERSON
SOCIAL SECURITY NUMBER
1.
Did you lend or give away any property or cash after notification of the overpayment? . . . . . . . . . . . . . . . . .
YES
NO
If Yes, how much?______________
2.
List all dependents who live with you.
________________________________________________
______________________________________________
________________________________________________
______________________________________________
3.
How much money do you have available in each of the following items? (Include any account on which your name appears either
in the U.S. or another country.)
CASH
SAVINGS ACCOUNT
CHECKING ACCOUNT
STOCKS/BONDS
$
$
$
$
MONEY OR MUTUAL FUNDS
TRUST FUNDS
CERTIFICATES OF DEPOSIT (CD)
OTHER
$
$
$
$
4.
Do you own more than one motor vehicle? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, describe below:
YEAR, MAKE/MODEL
PRESENT VALUE
LOAN BALANCE
5.
Do you own any real estate (buildings or land) other than where you live? . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, describe below:
PRESENT VALUE
LOAN BALANCE
HOW IS IT USED?
$
$
YOURS
SPOUSE’S
6.
Show monthly income that you and your spouse receive:
Wages or Self Employment earnings (Gross)
$
$
Wages or Self Employment earnings (Net)
$
$
Social Security Benefits
$
$
SSI or other Public Assistance
$
$
Food Stamps (Full face value)
$
$
Rental income
$
$
Child Support/Alimony
$
$
Other
$
$
Total Income
$
$
7.
Show monthly household expenses
Rent or Mortgage
$
Food
$
Utilities (gas, electric, telephone)
$
Water, sewer, garbage
$
Clothing
$
Insurance
$
Medical expenses (Not covered
Car or other
by Medi-Cal or other insurance)
$
transportation
$
Loan payments
Support to someone not
(minimal amounts)
$
in household
$
Total expenses
$
I declare under penalty of perjury under the laws of the State of California that the answers I have given are correct and true to
the best of my knowledge.
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE
DATE
RESIDENCE ADDRESS:
PHONE NUMBER
CITY
STATE
ZIP CODE
SOC 807 (7/00)

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