Form Sar 72 - Sponsor'S Semi-Annual Income And Resources Report (Supplement To The Sar 7) Page 2
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8.
Since your last report, was there a change in the number of persons who are claimed as
YES
NO
dependents for federal income tax purposes by you or your spouse? If “YES”, complete below.
DOES PERSON LIVE
DATE OF
NAME OF PERSON(S)
EXPLAIN WHAT CHANGED
WITH SPONSOR?
CHANGE
■
■
YES
NO
■
■
YES
NO
■
■
9.
Since your last report, was there any change in payments made to persons who are claimed as federal tax
YES
NO
dependents who are not living with you or your spouse?
If “YES”, explain what changed, list the name of the person(s), amount paid and who paid:
■
■
10. During the Report Month, did you or your spouse pay any court-ordered support?
YES
NO
If “YES”, enter the amount paid and attach receipts: $
■
■
11. Do you or your spouse have any other information to report such as: A new address, a change in the number
YES
NO
of noncitizens you sponsor and who will get cash aid, recent or anticipated changes in income, etc.?
If “YES”, explain the change and if you know if it will be temporary or permanent, and give the date of the
change.
CERTIFICATION SECTION
•
I understand that the term for sponsorship is normally an indefinite period of time.
•
I understand that failure to report information or purposely giving the wrong facts for cash aid is a crime and I can be fined, go to jail
or both.
•
I understand that I may have to pay back any benefits that are overpaid because I did not give all of the facts or gave the wrong
information.
SPONSOR’S CERTIFICATION
•
I declare under penalty of perjury under the laws of the State of California that the information in this report is true, correct and
complete.
SIGNATURE OF SPONSOR
DATE
SIGNATURE OF SPONSOR’S SPOUSE (IF LIVING TOGETHER OR SIGNED AN AFFIDAVIT OF SUPPORT)
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
NONCITIZEN’S CERTIFICATION
•
I have reviewed this signed and completed report from my sponsor(s). I declare under penalty of perjury under the laws of the State
of California that, to the best of my knowledge, the information in this report is true, correct and complete.
DATE
DATE
COUNTY USE ONLY SECTION
Evaluation of Sponsor/Sponsor’s Spouse
CalWORKs
CalFresh Sponsor/Sponsor’s Spouse
Real/Personal Property Resources
Sponsor/Sponsor’s Spouse Income Computation
Income Computation
A.
Earned Income
$ ____________
A.
ITEMS
VALUE
______________
$_______________
A.
Earned Income
$ __________
B.
Less 20%
- ____________
______________
$_______________
B.
Unearned Income
+ __________
C.
Unearned Income
+ ____________
______________
$_______________
D.
Gross Income Deduction
______________
$_______________
C.
Subtotal
= __________
for sponsor’s household
______________
$_______________
D.
Total number of sponsored
size
- ____________
noncitizens applying for/receiving
B.
Total
$ _______________
E.
Subtotal
= ____________
CalWORKs
__________
CW
CF
C.
Less: CalFresh
F.
Total number of sponsored
NA
$1500
Deduction ($1500)
- _____________
E.
Divide C by D
= __________
noncitizens applying
D.
Subtotal
= _______________
for/receiving CalFresh
____________
F.
Number of sponsored noncitizens
E.
Total number of sponsored
in this AU
__________
G.
Total (Divide E by F)
= ____________
noncitizens applying
for/receiving CW/CF
_______________
G.
Total (Multiply E by F)
= __________
F.
Total (Divide D by E) = _______________
Amount in G to be deemed income for each
Amount in F to be included in each noncitizen’s
Amount in G to be deemed income for entire AU.
sponsored noncitizen.
property limits.
PAGE 2 OF 2
SAR 72 (3/13) REQUIRED FORM - SUBSTITUTE PERMITTED
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