Form Dhcs 7044 - California Statement Of Living Arrangements In-Kind And Maintenance - Health And Human Services Agency
ADVERTISEMENT
1
2State of California – Health and Human Services Agency
Department of Health Care Services
STATEMENT OF LIVING ARRANGEMENTS, IN-KIND AND MAINTENANCE
Print in Ink.
Applicant’s name (print first name, middle, last name)
Applicant’s social security number
Spouse’s name (print if spouse is applying or receiving benefits)
Spouse’s social security number
PART I
A. Check the blocks which best describe your living arrangements.
1. I live (with):
Alone
Spouse
Minor child(ren)
Parent(s)
Other (specify):
________________________________
2. I live in a:
House
Apartment
Room (commercial establishment)
Room (private home)
Mobile Home
Other (specify):
________________________________
3. Total number of people in household (including yourself)
______________
B. Check “Yes” or “No” to the questions below.
1. Do you (and/or your spouse) own or are you buying the home you live in?
Yes
No
If “Yes,” go to question C.
2. Do you (and/or your spouse) rent the place where you live?
Yes
No
If “Yes,” go to question 4.
3. Does anyone who lives with you (other than your spouse) rent or are they buying the place where you live?
If “No,” go question C.
Yes
No
4. Are you or anyone you live with related to the landlord (landlord’s spouse or person purchasing the house?
Yes
No
If “Yes,” indicate relationship……………………………………………..___________________________________
5. If you answered “Yes” to 2 or 3, provide the following information:
Landlord’s or buyer’s name
Landlord’s or buyer’s address
City
State
ZIP Code
Landlord’s or buyer’s telephone number
Date rental agreement or purchase began (month/year)
Monthly rental or mortgage payment amount
C. Does any agency, organization, or anyone who does not live with you pay, or help you
Yes
No
pay, for any of the following items: food, rent, home mortgage payments, property
insurance, real property taxes, heating fuel, gas, electricity, garbage, water, and/or
sewer bills?
If “yes,” please provide the following information about each item you receive; then go to question D.
CONTRIBUTOR’S NAME, ADDRESS, AND TELEPHONE NUMBER
Frequency
In
In-
Dollar
ITEM
of Payment
Cash
Kind
Value
Name
Address
Telephone Number
DHCS 7044 (12/08)
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (hmong) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (arabic) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (armenian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (chinese) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (korean) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (laotian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (russian) - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal