Form Qr 377.5 - Food Stamp Mid - Quarter Status Report
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1STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOOD STAMP MID-QUARTER STATUS REPORT
INSTRUCTIONS:
Use this form to report ABAWD and/or address changes that have occurred since your last Quarterly Report (QR 7).
Use this form to report changes you think will increase your food stamp benefits, please provide proof, such as, pay stubs; copies of checks;
letters from agencies, etc.
If you are reporting changes in expenses, please provide proof, such as, receipts; canceled checks, paid invoices; etc.
•
•
Worker:
Phone:
MANDATORY ABAWD INFORMATION
Answer for any Able-Bodied Adult without Dependents (ABAWD) in your household:
The number of hours worked or in training dropped from 20 hours a week or 80 hours a month to _______ hours a week
or _______ hours a month.
In the week(s) of ___________ ___________ ____________ ____________ ___________ ___________ ___________
In the month(s) of
Name of Person(s)
Relationship to You
Explain What Happened
CHANGE OF ADDRESS
NEW HOME ADDRESS (NUMBER, STREET NAME, AVENUE, BLVD, ETC.)
CITY
STATE
ZIP CODE
NEW PHONE
DATE MOVED
NEW MAILING ADDRESS (IF DIFFERENT FROM HOME ADDRESS)
CITY
STATE
ZIP CODE
ARE YOU GETTING FREE RENT AT THE NEW ADDRESS YOU HAVE LISTED?
ARE YOU GETTING FREE UTILITIES AT THE NEW ADDRESS YOU HAVE LISTED?
YES
NO, IF NO, AMOUNT OF RENT $
YES
NO, IF NO, AMOUNT OF UTILITIES$
VOLUNTARY INFORMATION (All household/s Assistance Units)
I would like to report the following information:
CERTIFICATION
I UNDERSTAND THAT: If on purpose I do not report all facts or give wrong facts about my income, property, or family status to
get or keep getting aid or benefits, I can be legally prosecuted. And, I may be charged with committing a felony if more than $400
in food stamp benefits is wrongly paid out.
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 and correct and complete.
WHO MUST SIGN
Head of household, household member or the household’s authorized representative.
BELOW:
Date Signed
Home Phone
Contact Phone
Signature or Mark
Date Signed
Signature of Witness to Mark, interpreter or
Date Signed
Signature of Spouse or other Parent of Cash Aided
other person completing form
Children, Adult Household Member or Authorized
Representative
QR 377.5 (2/04) RECOMMENDED FORM
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