Form Sar 72 - Sponsor'S Semi-Annual Income And Resources Report (Supplement To The Sar 7)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REPORT MONTH:________________
SPONSOR’S SEMI-ANNUAL INCOME AND RESOURCES REPORT (Supplement to the SAR 7)
TO KEEP YOUR BENEFITS COMING ON TIME, PLEASE GIVE THIS FORM TO YOUR SPONSOR. YOU AND YOUR SPONSOR(S) MUST SIGN AND
DATE THIS FORM AFTER THE LAST DAY OF THE REPORT MONTH AND RETURN IT BY THE 5th OF __________________WITH YOUR SAR 7.
(MONTH)
CASE NUMBER
NEED HELP? (County specific instructions w/county unurl)
Worker Name: _____________________ [Dist. ID here]
Worker Phone : (
) ________________________
County:___________________________________________
Street Address:_____________________________________
City, State, Zip Code_________________________________
Barcode:
SPONSOR’S INSTRUCTIONS
You and your spouse (if living together or if your spouse has signed an affidavit of support) must complete and sign this report after
the end of the Report Month listed at the top of this form and return it immediately to the non-citizen you sponsor.
Call the county if you need help completing this form.
1.
Sponsor’s Name (First, Middle, Last)
Answer the following questions for your spouse if he/she is living with you OR signed an affidavit of support.
2.
Spouse’s Name (First, Middle, Last)
Has spouse signed an affidavit of support?
YES
NO
3.
Do you and/or your spouse get cash aid, such as CalWORKs or SSI? If “YES”, complete below.
YES
NO
STATE
CASE NAME
DATE OF BIRTH
TYPE OF CASH AID
COUNTY
4.
During the Report Month did you and/or your spouse get income, money or benefits, such as: earnings,
YES
NO
training payments, earned income tax credit, strike benefits, social security, railroad retirement, unemployment
or disability insurance, interest, worker’s compensation, SSI/SSP, child/spousal support, loans, grants, tax
refunds, cash gifts, free housing/utilities, etc.?
If “YES”, list WHO got income, employer’s name or other source of income, GROSS amount BEFORE
deductions (such as taxes, social security or other retirement deductions, garnishments, support, etc.) and
actual date they got the income. Attach paystubs or other proof of earnings for the Report Month. Attach proof
of any other type of income only when it starts and when it changes.
If self-employed, list business expenses on a separate sheet of paper and attach proof of income and expenses.
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
5.
Will there be any changes to this income in the next six months? If “YES”, list below what change is
YES
NO
expected. Attach any proof you may have such as: a letter from an employer, benefit award letter, etc.
How and when will it change?
Whose income will change?
What income will change?
If both you and your spouse (if living with you) receive Cash Aid, skip to Question 11 and complete the Certification Section.
6.
Since your last report, did you or your spouse have any changes in personal and/or real property, such as:
YES
NO
Got, bought, sold, traded, or gave away a motor vehicle, camper, boat, land or house, etc.? If “YES”, please
explain the type of change and the amount, if applicable.
7.
Did you or your spouse have a checking, savings or credit union account at the end of the Report Month? If
YES
NO
“YES”, complete below.
Whose Account?
Balance On Last Day of
Whose Account?
Balance On Last Day of
Credit Union
Credit Union
Report Month
Report Month
Checking
Checking
Savings
Savings
$
$
COUNTY USE ONLY
WORKER INITIALS
DATE
SAR 72 (3/13) REQUIRED FORM - SUBSTITUTE PERMITTED
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