Form Mc 176 Tmc - Transitional Medi-Cal (Tmc) Quarterly Status Report Page 2
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1
2❒ Yes
❒ No
3.
a.
Did you or any family member receive free housing, utilities, food, or clothing in the report month?
❒ Yes
❒ No
b.
Did you or any family member work for housing, utilities, food, or clothing in the report month?
If yes to 3a and 3b, you must answer the three questions on the next line.
(1) What was received?
(2) Who received it?
(3) Who provided it?
❒ Yes
❒ No
4.
Did you or anyone pay for child care expenses which have not or will not be reimbursed?
If yes, complete the following:
Amount Paid for Child Care Expenses
Name of Child(ren)
Age
Month 1
Month 2
Month 3
Name of Child Care Provider
5.
Did you have changes in your family or household during the time specified? (Include change of address,
change of child care provider, change of employment, change in property, anyone that moved into or out
❒ Yes
❒ No
of your home, is pregnant, or anyone who was born or who died.)
If yes, complete the following:
Name
Relationship
What Happened
Date
6.
a.
Do you or anyone have or expect to receive private health, vision, or dental insurance? (This includes
❒ Yes
❒ No
insurance paid by an absent parent.)
❒ Yes
❒ No
b.
Do you have or expect to receive health insurance through your employer?
❒ Yes
❒ No
c.
Does your employer offer health insurance for a monthly premium?
If yes, complete the following:
Name of Insurance
Person(s) Insured
CERTIFICATION
I understand that reported facts may result in benefits being changed or stopped.
I understand that the statements I have made on this form are subject to investigation and verification.
I understand that I must notify my worker within ten days of any change.
I understand that failing to report facts or giving wrong or incomplete facts can result in legal prosecution with penalties of a fine,
imprisonment, or both.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES AND THE STATE OF CALIFORNIA THAT
THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND CORRECT AND IS COMPLETE FOR THE ENTIRE REPORT PERIOD.
Signature or mark of applicant
Date
Phone number
(
)
Signature of witness to mark, interpreter, or other person
Date
Phone number
(
)
MC 176 TMC (05/07)
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