Form Sar 23 - Senior Parent Statement Of Facts
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SENIOR PARENT
CASE NAME
STATEMENT OF FACTS
CASE NUMBER
(Supplement to the SAWS 2)
The rules say that when a minor parent (up to age 18) applies for cash aid, we must count the income of the senior parent(s) living in the
same home. We will figure how much of this income will be counted.
INSTRUCTIONS:
●
Fill in this form and return it with your SAWS 2. Answer all of
●
If we do not get a complete form, your cash aid and cash-based
the questions about your parent(s) who lives with you.
Medi-Cal may be changed or stopped.
●
If you have questions, ask your worker or call the county.
■ ■
■ ■
1.
Does your parent(s) get income, money, or benefits, such as:
YES
NO
Earnings; government benefits like Social Security, Unemployment/Disability Benefits (UIB/DIB),
Supplemental Security Income/State Supplementary Payment (SSI/SSP), worker’s compensation; railroad
retirement, veterans or other private or government disability retirement; interest or dividends from stocks,
bonds, savings accounts; In-Home Supportive Services (IHSS); child/spousal support; training payments;
strike benefits; cash, gifts, loans, grants, scholarships; tax refunds; Earned Income Tax Credit (EITC);
gambling/lottery winnings; rental income, rental assistance; free housing/utilities/clothing or food; insurance or
legal settlements; etc.?
NAME
SOURCE
AMOUNT RECEIVED
HOW OFTEN
$
NAME
SOURCE
AMOUNT RECEIVED
HOW OFTEN
$
■ ■
■ ■
2.
Will there be any changes to this income in the next six months?
YES
NO
If “YES”, list below what change is expected. Attach any proof they may have such as: a letter from an
employer, benefit award letter, etc.
WHOSE INCOME WILL CHANGE?
HOW AND WHEN WILL IT CHANGE?
■ ■
■ ■
3.
Does your parent(s) support other persons living in the home and claim them as Federal tax dependents?
YES
NO
If “YES”, list name of person(s) and relationship.
NAME
RELATIONSHIP
NAME
RELATIONSHIP
■ ■
■ ■
4.
Does your parent(s) support anyone not living in the home and claim or could claim that person as a Federal
YES
NO
tax dependent? If “YES”, give name of person(s), amount paid and ATTACH PROOF.
AMOUNT PAID
NAME
AMOUNT PAID
NAME
$
$
CERTIFICATION
I understand that if on purpose I do not report all facts, or give wrong information to get aid, I can be legally prosecuted. I can be
●
charged with committing a serious crime if I get more than $950 in aid that I am not supposed to get. And my cash aid can be stopped
for a period of time. I may be fined up to $10,000 and/or sent to jail or prison for up to 3 years.
I understand that failing to report information or true facts can result in legal prosecution with penalties of a fine, imprisonment or both.
●
I understand that I must call my worker to report any unexpected changes which may affect my eligibility for or the amount of my Cash
●
Aid within 5 days of the change. If I am unsure about needing to report any changes, I must contact my worker.
I understand that the facts I report may result in my benefits being denied, lowered or stopped.
●
I understand that I have the right to request a State Hearing on any proposed action by the County Welfare Department.
●
I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this report are
true, correct, and complete.
YOU MUST SIGN AND DATE THIS REPORT OR IT WILL BE INCOMPLETE
☛
SIGNATURE OF CASH AIDED MINOR PARENT
DATE SIGNED
COUNTY USE ONLY
SAR 23 (3/13) REQUIRED FORM - SUBSTITUTE PERMITTED
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