Form Mc 210 S-I - Income In-Kind/housing Verification
Download a blank fillable Form Mc 210 S-I - Income In-Kind/housing Verification in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Mc 210 S-I - Income In-Kind/housing Verification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2State of California—Health and Human Services Agency
Department of Health Care Services
INCOME IN-KIND/HOUSING VERIFICATION
(SUPPLEMENT TO THE MC 210 STATEMENT OF FACTS)
COUNTY USE ONLY
Case name
WE NEED THE FOLLOWING INFORMATION TO DETERMINE THE
VALUE OF THE HOUSING/RENT, UTILITIES, FOOD, OR CLOTHING
Case number
THAT YOU ARE RECEIVING FREE OR IN EXCHANGE FOR WORK.
Eligibility worker number
Date
PART I. (IN-KIND INCOME VERIFICATION)
A. Applicant Authorization Section (Sign this section if you want the county to verify IN-KIND INCOME.)
Name(s)
Address (number, street)
City
ZIP code
I hereby authorize _____________________________ County to contact _______________________________________
concerning any of the information requested below.
Applicant signature
Date
B. Provider Statement Section (Statement of person giving/sharing housing, utilities, food, clothing, etc.)
1. The person(s) named above receives from me/my family:
❒ Housing/Rent
❒ Utilities
❒ Food
❒ Clothing
❒ Cash
❒ free
❒ in exchange for ___________________________________________________________________________
This is
"
I/We have been providing these items since________________________________________________________
"
I/We expect to continue to provide these items until__________________________________________________
"
❒ Yes
❒ No
2. I/We share household expenses with the person(s) named above.
(If no, go to number 3.)
Our shared arrangement is ________________________________________________________________________
3. List the TOTAL cost of household items at the above address.
Housing
Rent
Utilities
Food
Clothing
Cash
$
$
$
$
$
$
The number of people in the household at the above address is ________________________________________
"
4. My relationship to the person(s) named above is _______________________________________________________
I CERTIFY THAT THE INFORMATION IN THIS SECTION IS TRUE AND CORRECT.
Provider signature
Date
Address (number, street)
City
State
ZIP code
Telephone number
(
)
PART II. HOUSING VERIFICATION
SIGN BELOW ONLY IF YOU, THE APPLICANT, WANT TO PROVIDE INFORMATION ABOUT FREE HOUSING OR RENT PAID
TO A RELATIVE AS EVIDENCE OF RESIDENCY. BEFORE YOU SIGN, YOU MUST FILL IN THE HOUSING INFORMATION
REQUESTED ABOVE.
I understand that the information I provide as evidence of residency may be verified by county or state employees processing
my application.
I agree to cooperate with any such employee in the verification of this information.
I hereby authorize any county or state employee responsible for administering the Medi-Cal program to
contact __________________________________________________ concerning any of the information provided above.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
INFORMATION CONTAINED IN THIS STATEMENT IS TRUE, CORRECT, AND COMPLETE.
Applicant signature
Date
MC 210 S-I (09/08)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal