Form Qr 72 - Sponsor'S Quarterly Income And Resources Report
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSOR’S QUARTERLY INCOME AND RESOURCES REPORT
THIS REPORT IS FOR THE MONTH OF
GIVE THIS TO YOUR SPONSOR
COMPLETE, SIGN, DATE AND RETURN THIS FORM AFTER:
CASE NAME
CASE NUMBER
SPONSOR’S INSTRUCTIONS
•
You and your spouse (if living together or if spouse has signed an affidavit of support) must complete and sign this report and return
it immediately to the noncitizen you sponsor.
•
The noncitizen must complete, sign and date the form, and return it to the county by the 5th of the month. If a complete report,
including verification, is not received by the 11th of the month, the noncitizen’s Cash Aid may be delayed, lowered, or stopped.
•
Call the county if you need help completing this form.
Noncitizen’s Name and Address
•
•
•
•
WORKER:
PHONE:
Sponsor’s Name (First, Middle, Last)
1
Answer the following questions for your spouse if she/he is living with you OR has signed an affidavit of support.
Sponsor’s Spouse’s Name (If Living Together) ( First, Middle, Last) Has sponsor’s spouse signed an
YES
NO
2
affidavit of support?
Do you and/or your spouse receive Cash Aid, such as California Work Opportunity and Responsibility to
YES
NO
3
Kids (CalWORKs) or Supplemental Security Income (SSI)?
If YES, complete below.
STATE
CASE NAME
DATE OF BIRTH
TYPE OF CASH AID
COUNTY
During the report month did you and/or your spouse receive income, money or benefits, such as: earnings,
YES
NO
4
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 refund, cash gifts, free housing/utilities, etc.?
If YES, list who received income, employer’s name or other source of income, gross amount before
deductions, and actual date received. Attach paystubs or other proof of earnings for the report month.
Attach proof of any other 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
If both you and your spouse (who is living with you) receive Cash Aid, skip to Question 10 and complete the Certification Section.
Since your last quarterly report, did you or your spouse have any changes in personal and/or real property,
YES
NO
5
such as: Receive, buy, sell or give away a motor vehicle, camper, boat, land or house, etc.?
If YES, explain the type of change, date of change and the amount, if applicable.
Did you or your spouse have a checking, savings or credit union account at the end of the report month?
YES
NO
6
If 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
QR 72 (12/06) REQUIRED FORM - SUBSTITUTE PERMITTED
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