Form Soc 453 - Cash Assistance Program For Immigrants (Capi) - Statement Of Household Expenses And Contributions Page 2

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State of California – Health and Human Services Agency
California Department of Social Services
yourself, spouse, children, and all others. Enter the full monthly rent or mortgage for the house
or apartment (not just what you pay), the cost of food for everyone, etc.
Monthly food cost for entire household (if you answered “yes” to Question 9, please enter
zero):
$_________
Total monthly rent or mortgage:
$_________
Property insurance:
$_________
Property taxes:
$_________
Gas (for heating, cooking, etc.):
$_________
Electric:
$_________
Water:
$_________
Sewer:
$_________
Garbage:
$_________
11. If you share household expenses with others who live with you (other than your spouse, if any),
write the amount that you (and your spouse, if any), contribute in cash each month. (If you live
alone or just with your spouse, please write “0”): $_________
12. What date did you start contributing the amount listed in Question #11(month/day/year)?_______
PART C: SIGNATURE – If the CAPI applicant/recipient pays household expenses to another
person who lives in the same residence, or shares expenses with a person who lives in the
same residence, that other person (called “Head of Household”) must review this form, verify
that it is accurate and sign below.
CAPI Applicant/Recipient
I declare, under penalty of perjury under the laws of the State of California, that all answers that I
have given and all statements on this form are correct and true to the best of my knowledge.
________________________________________________________________________________
Signature of Applicant/Recipient:
Date:
Head of Household
I declare, under penalty of perjury under the laws of the State of California, that all the information
above regarding total household expenses and the CAPI applicant’s/recipient’s cash contributions is
correct and true to the best of my knowledge.
________________________________________________________________________________
Signature of Head of Household:
Date:
Telephone Number:
FOR OFFICIAL USE ONLY
Total monthly household expenses (TMHA):
$______________
To calculate pro rata share, divide TMHA by number of people
(including adults and children) residing in household:
$______________
SOC 453 (1/18)
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