Form Qr 72 - Sponsor'S Quarterly Income And Resources Report Page 2
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1
2Since your last quarterly report, was there a change in the number of persons who are claimed as depen-
YES
NO
7
dents 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
Since your last quarterly report, was there any change in payments made to persons who are claimed as
YES
NO
8
federal tax 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:
During the report month, did you or your spouse pay any court-ordered support?
YES
NO
9
If YES, enter the amount paid and attach receipts: $
Do you or your spouse have any other information to report such as: a new address, a change in the
YES
NO
10
number of noncitizens that you sponsor and who will receive Cash Aid, recent or anticipated changes in
income, etc.?
If YES, explain the change and if it is expected to be temporary or permanent, and give the date of 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 misrepresentation of facts for Cash Aid can result in legal prosecution with penalties
of a fine, imprisonment or both.
•
I understand that I may be required to repay any benefits which are overpaid because of incorrectly or incompletely reported
information.
SPONSOR’S CERTIFICATION
•
I declare under penalty of perjury under the laws of the State of California that the information contained in this report is true and
correct and is 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 contained in this report is true and correct and is complete.
NONCITIZEN’S OR DECLARANT’S SIGNATURE OR MARK
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
COUNTY USE ONLY
Evaluation of Sponsor/Sponsor’s Spouse
CalWORKs
Food Stamps 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
FS
C.
Less: Food Stamp
F.
Total number of sponsored
NA
$1500
Deduction ($1500)
- _____________
E.
Divide C by D
= __________
noncitizens applying
D.
Subtotal
= _______________
for/receiving Food
F.
Number of sponsored noncitizens
E.
Total number of sponsored
in this AU
__________
Stamps
____________
noncitizens applying
G.
Total (Divide E by F)
= ____________
for/receiving CW/FS
_______________
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
QR 72 (12/06) REQUIRED FORM - SUBSTITUTE PERMITTED
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