Form Dhcs 7044 - California Statement Of Living Arrangements In-Kind And Maintenance - Health And Human Services Agency Page 2
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
D. If you live with others, do all the other household members receive some type of public
Yes
No
payment based on need (e.g., AFDC,SSI,VA)?
If “Yes,” indicate below which agency. If “No,” go to Part II.
Agency Name
PART II
Complete Part II if you live with at least one person other than, or in addition to, your spouse or minor
child(ren).
A. What is the monthly amount of the following household cash expenses:
Food
$_________________
Electricity
$________________
Mortgage or Rent
_________________
Gas
________________
Property Insurance
_________________
Water
________________
Real property taxes
_________________
Sewer
________________
Heating fuel
_________________
Garbage
________________
TOTAL
$__________________
B. How much is your cash contribution per month toward the household expenses
$ _________________
list in item A?
C. If you or your spouse own or rent, show the total monthly cash contributions
$ _________________
from others with whom you live.
SIGNATURES
Your signature (first name, middle initial, last name) (Sign in ink)
Date (month, day, year)
Sign
»
Here
Spouse’s signature if spouse is applying (first name, middle initial, last name) (Sign in ink)
Date (month, day, year)
Sign
»
Here
Mailing address (number and street, apartment number, P.O. Box, or rural route)
City
State
Zip code
County
PART III—FOR COUNTY USE ONLY –(To compute rebut calculation for PMV ISM)
1. Total shelter expenses
$ _________________
2. Total number of household members
_________________
3. Pro rata share of household expenses per person (divide 1 by 2)
_________________
4. Pro rata share per person multiplied by number of applicants
_________________
5. Subtract applicants contribution
_________________
6. Actual PMV ISM
$ _________________
7. Allocated amount of PMV ISM (from Pickle Handbook)
_________________
8. If line 6 exceeds line 7, line 7 is not rebutable
_________________
DHCS 7044 (12/08)
Page 2 of 2
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