Form Soc 860 - Sponsor'S Statement Of Facts Income And Resources
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSOR’S STATEMENT OF FACTS
INCOME AND RESOURCES
(Supplemental Application for Cash Assistance Program for Immigrants)
COUNTY USE ONLY
(TO BE COMPLETED BY SPONSOR AND SPONSOR’S SPOUSE, IF APPLICABLE)
CASE NAME:
INSTRUCTIONS: PLEASE ANSWER THE FOLLOWING QUESTIONS FOR YOURSELF
CASE #:
AND YOUR SPOUSE (IF LIVING TOGETHER) AND RETURN IT TO THE CAPI
APPLICANT/RECIPIENT OR THE COUNTY REPRESENTATIVE.
WORKER #:
CAPI Applicant/Recipient Name and Address
The information you provide on this statement is on behalf of the noncitizen indicated above to determine
his/her eligibility for the Cash Assistance Program for Immigrants (CAPI).
Proof may be needed to verify answers to the following questions. Attach proof when the form asks for it.
DATE OF BIRTH
1.
SPONSOR’S SOCIAL SECURITY NUMBER (VOLUNTARY)*
TELEPHONE NUMBER
NAME (FIRST, MIDDLE, LAST)
(
)
HOME ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS (IF DIFFERENT THAN HOME ADDRESS)
2.
DATE OF BIRTH
SPOUSE’S SOCIAL SECURITY NUMBER (IF LIVING TOGETHER) (VOLUNTARY)*
VERIFIED:
HAS SPONSOR’S SPOUSE SIGNED AN
NAME (FIRST, MIDDLE, LAST)
Affidavit of Support on
AFFIDAVIT OF SUPPORT?
File
YES
NO
USCIS Verification
3.
Do you or your spouse get assistance such as: California Work Opportunity
and Responsibility to Kids (CalWORKs), Food Stamps, or Supplemental
Other: ____________
YES
NO
Security Income (SSI)? If Yes, complete below:
VERIFIED:
CASE NAME
TYPE OF ASSISTANCE
MONTHLY AMOUNT
COUNTY
STATE
$
Letter on File
Verbal Communication
$
Other: ____________
4.
Do you or your spouse have other persons who are claimed or could be
claimed as dependents for federal income tax purposes?
YES
NO
IRS Form 1040
NAME OF PERSON(S)
RELATIONSHIP
DATE OF BIRTH
DOES PERSON LIVE WITH SPONSOR?
Reviewed
Other: ____________
YES
NO
YES
NO
YES
NO
YES
NO
4A. I currently provide the following amount of support each month to the CAPI applicant(s)/recipient(s) named at the top of this form:
MONTHLY AMOUNT OF CASH SUPPORT PROVIDED:
$______________________
OTHER NON-CASH SUPPORT (Shelter, food, transportation, clothing, etc.) Please describe: ______________________________ _
__________________________________________________________________________________________________________
SOC 860 (12/16)
PAGE 1
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