Form Soc 157c - Standardized Silp Readiness Assessment Tool Page 2
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8STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
The Social Worker or Probation Officer and the Nonminor Dependent should complete this assessment
together. It may take up to 45 minutes to complete.
Name: ___________________________________ SW/PO Name: ______________________________
Address of proposed SILP: ________________________________________________________________
NMD plans to live:
alone or with child only
with roommates
with supportive adult
Other relevant information about the proposed SILP: ____________________________________________
______________________________________________________________________________________
Section 1: FINANCIAL PLAN
Using the budgeting tool provided below, have the NMD list out their projected income and expenses to
calculate whether they can afford the proposed SILP.
Monthly Sources of Income
Monthly Expenses
1.
SILP payment:
$_____________
1.
Rent:
$___________
2.
Utilities:
$___________
2.
__________________: $_____________
3.
Cable/Internet:
$___________
4.
Food:
$___________
3.
__________________: $_____________
5.
Household items:
$___________
(e.g. toilet paper, cleaning supplies)
4.
__________________: $_____________
6.
Personal/Hygiene:
$___________
7.
Cell Phone:
$___________
Total:
$_____________
8.
Clothing/Shoes:
$___________
0.00
9.
Car payment:
$___________
List all sources of income above and the expected monthly
10. Car insurance:
$___________
amount from that source. This should include wages
11. Gas:
$___________
from employment, financial aid and any other sources of
12. Car repair/maintenance:
$___________
income.
13. Educational expenses:
$___________
14. Entertainment:
$___________
15. Child-related expenses:
$___________
(e.g. diapers, formula, baby food,
clothing, toys, books)
16. Savings:
$___________
17. Other: ______________
$___________
18. Other: ______________
$___________
Total:
$___________
0.00
TOTAL MONTHLY INCOME:
$_____________
TOTAL MONTHLY EXPENSES:
$___________
0.00
0.00
Total monthly income $ ___________ minus total monthly expenses $ __________ = $___________
0.00
0.00
0.00
1. Is the NMD’s income greater or equal to their expenses?
Yes
No
2. If additional income is needed beyond the SILP payment to meet the NMD’s expenses, does the NMD
have stable income?*
Yes
No
N/A
*Examples of unstable income include seasonal work, such as holiday retail or summer recreation; vendor work, such as selling
items at flea markets, farmer’s markets, etc.; self-employed without history of steady income; “pick-up” work, such as filling in for a
friend who paints houses; etc. In addition, if the NMD is in a very new position, it may not yet be considered stable.
3. If housing unit requires payment of a security deposit does NMD have funds available or a plan for paying
the deposit? **
Yes
No
N/A
4. If a rent payment(s) is due before the first SILP payment will be received, does the NMD have the funds to
cover the rent payment(s) or have an alternate arrangement to take care of the payment(s)?**
Yes
No
N/A
If the NMD does not have these funds available, other funding sources/options should be explored, including
ILP funds.
**If NMD does not have the necessary funds available, the SILP readiness assessment should be denied with a plan added to the
NMD’s TILP for how the NMD will obtain the necessary funds.
IF ANY OF THE ABOVE QUESTIONS ARE ANSWERED NO, THIS SILP SHOULD NOT BE APPROVED.
SOC 157C (7/17) (Optional)
PAGE 2 OF 8
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