Form Soc 453 - Cash Assistance Program For Immigrants (Capi) - Statement Of Household Expenses And Contributions

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State of California – Health and Human Services Agency
California Department of Social Services
CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)
STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
This form must be completed by the applicant/recipient when applying for CAPI and also at
every redetermination.
Applicant’s or Recipient’s Name:
Case Number:
Residence Street Address (if homeless, please indicate):
Residence City, State and ZIP Code:
Telephone Number:
Message Telephone Number:
PART A: LIVING ARRANGEMENTS
1. What date did you move to this address? __________________
2. How many people live in this residence? (Please count yourself, your spouse, children and all
others.) __________
3. Do all other household members receive some type of public assistance such as CalWORKs,
BIA, SSI/SSP, VA Pension, CAPI or General Assistance?
Yes
No
n
n
4. Do you or your spouse OWN the home you live in (or are you in the process of buying it?)
Yes
No
n
n
5. Do you or your spouse RENT the home you live in?
Yes
No
n
n
6. Are you (or anyone who lives with you) the parent or child of the landlord or the landlord’s
spouse?
Yes
No
n
n
7. Does any organization or person who does not live with you help you (or your spouse) pay for
food, rent, mortgage, property insurance, utility bills, or other household expenses?
Yes
No (If “no,” skip to Question #9.)
n
n
8. If you answered “yes” to the above question, please list the item paid for, who pays for it, and
the monthly amount paid for it.
Item #1: ______________________________________________________________________
Contributor’s Name: _________________________________ Monthly Amount: $___________
Item #2: ______________________________________________________________________
Contributor’s Name: _________________________________ Monthly Amount: $___________
9. Do you buy all your own food?
Yes
No
n
n
PART B: TOTAL HOUSEHOLD EXPENSES
These are the expenses paid by the entire household, not just the applicant/recipient.
10. Please enter the amount the entire household pays each month for the following items.
Write in the total amount paid on behalf of everyone who lives in this residence, including
SOC 453 (1/18)
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