Form Qr 73 - Senior Parent Quarterly Income Report
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NAME:
SENIOR PARENT
CASE NUMBER:
QUARTERLY INCOME REPORT
THIS REPORT IS FOR THE MONTH OF:
(Supplement to the QR 7 - Use for unaided senior parent.)
The rules say that when a minor parent (up to age 18) gets 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 for m and retur n it with your Quar terly
If we do not get a complete report by the 11th day of the
Eligibility/Status Repor t (QR 7) by the 5th day of the
submission month, your cash aid and cash-based Medi-Cal may
submission month. Answer all of the questions about your
be delayed, changed or stopped.
parent(s) who lives with you.
If you have questions, ask your worker.
1.
During the report month did your parent(s) get income, money, or benefits, such as: earnings; government
YES
NO
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 account;
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?
If YES, list who received the money, the source, gross amount before deductions, and actual date received in
the report month. Attach paystubs or other proof of your parent’s earnings in the report month. If anyone is
self-employed, list business expenses on a separate sheet of paper and attach proof of income and expenses
in the report month. Proof for any self-employment income or other income is needed only when it starts and
when it changes.
GROSS AMOUNT
WHO GOT THE INCOME
SOURCE OF INCOME
$
$
$
$
$
ACTUAL DATE RECEIVED
GROSS AMOUNT
SOURCE OF INCOME
WHO GOT THE INCOME
$
$
$
$
$
ACTUAL DATE RECEIVED
2.
Do your parent(s) expect any changes in income in the next three 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.
What do you expect the total amount of
How will the income
List the source or type of
Who’s income will change?
income to be in each of the three months?
change?
income that will change.
Month_____
Month_____
Month _____
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 received more than $400 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 the facts I report may result in my benefits being changed or stopped.
I understand that I have the right to 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 and correct and are complete.
YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE MONTH OR IT WILL BE INCOMPLETE.
SIGNATURE OF CASH AIDED MINOR PARENT
DATE SIGNED
COUNTY USE ONLY
QR 73 (6/04) REQUIRED FORM - SUBSTITUTE PERMITTED
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