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FOOD STAMP HANDBOOK

63-1230 (Cont) ~--FORMS AND INSTRUCTIONS Handbook 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 CA 7 (2/84)

® Bid anyone have a checking, savings of credit union account open at the and of the manih?

HYVES. compiete hetow Cl yes C1 no

7 ast Oay p i Balance On Laat Da Whase Account? D Ceadit Union Baznce On Last Bay [Wise Acrount O Gaadic Unvon N ec + f Ms © checking of Repost Mon | G Checking cE Report Mam Gi Savings OD Savings

(@ Bid you mave, or da you have x new mailing address ot phone number?

1 YES, comelets below. __- Cl yes Ci no

fe Adgiess (Humber, Steet Name, Avenue Bivd Ele) [* Na. 7oiy State tip Tone Phone Na.

Mallia Racers (CU Oilierent Then Wome Rearess) ity ‘Siate Zip Cade

Hf. you -teeeive food. stamp:

Q) did the Rousshoid have havxing costa?

LT YES CINO

ft YES, enter amount Silled. haat or Mortgage Property Taxes oF insuracce {if not in margage) | ATTAGH lls only it you moved of the cost changed, ‘ : Did the hourshold have vtlity caste? ® ene you moved or tleim actual unility costs, complate below and ATTACH BILLS, ) ves C] wo Tas 7tual iy sal Geena Tinh War Sewage Dinar posit] t t ‘ ‘ 4 : t A G2) Bid the kovaeheld shara housing or utlitios or did anyone help pay these coma? ® YES, list each iter, amount paid, wha paid and ATTACH PROOF. Ci yes Cina

® Did sayans wha is disabled or age 60 or alder have eny medical expenses in the month? ¥ YES, compiete below and ATTACH BILLS for each axnense. no Hes the Expense? type of Expense

Cl ves C] wo

Type of Expanse

huriusghi G2) ‘the ‘honte. tf you donot tendive-cash Zaid! go:to

YES, enter the amount paid and ATTACH RECEIPTS: + Cl yes C] wo 15) Old anyone stort, stop or change health or hospitalizetion insurance ge such es ial, Blue Crowe, Chu ate? ® Ht YES, oive name of perron, daty and axolain change, Clyes C1 No

Did anyone become pregnant, hava a baby ac terminate & pregnancy? YES, sive name of person, dats and exp

Hyon Tereive cash aid or food ‘Stamps, answer (TD) » Answer!for evéryone in ‘the. household it-you teciive food Stamps. If you.do. not receive: toad ‘stamps, ‘answer for everyone: receiving cash: pits, “the aided chittiren's. patents, ‘stepparents, and-your spouse if my théchome.”

i) ase anyane in the home have ott place of employment, number of wa

information to report for thee month of wert month, svch bs: ecent Oe expacted changes inineone, Fy wae ing hours or days per weak place of residence, progerty, persons in the household, ec? | YES OQ N Q

Wt YES, expisin the change, if it is expected to be tamporery af permanent and indicate the date of the chenge.

CERTIFICATION @ f anderttend that fniting te report intormation or misrepresentation of tacts ter Cash Ald programs Food Stamps or Cast-basad Medial con rusut in fogul wet

” of + Gin, inp oF beth, In the Food Stamp Program the ponaties cam result ix permanent cisquattication trom the Program, tenes up te $10,000 of imprisooment for vp 10 § years.

@ =f understand thet | must contact ny worker to report any unexpected changes whici atiect my eligibility for ar the amount of my Cash Aid within 5 ays of the oxcurrence or itt hace any doubt shout navding to reaort any changes.

© / undertiand that repored information may result m a decrease or ditcoatinvance of benelits,

@ f understand | have the right to request a sate Auating on any propased action by the county welfare daparment.

G1 declare that the information conteiney in this report is true and correct 2nd is complete for the entire report month.

YOU MUST SIGH ANO OATE THIS REPORT AFTER THE LAST DAY GF THE REPORT MONTH OR IT Will SE CONSIDERED INCOMPLETE

For Cash Aid programs, you and yout aided spouse tor tha other parent of aided children Uving in the home must sign the form, For the Foad Stame Program, the head of household. 4 household member of the household's authorized representative must sigh the form.

Signaiuee of Cath "fad Parent or Caretaxee Relaseve ang.-or Food Stama Household Member Date Signed agnaiwe ot Cath Aided Spouse o Omer Purem mt Lash Aroed Chudren Dare Signed Signature oC Witness ie Mare. iterpitier Giver Perse Commuennay Form Date Signe

isin change. CJ yes 7) wo ;

CALIFORNIA-DSS-MANUAL-SS Issue 626 Issued 2/15/84

(MANUAL LETTER NO. 84-13) [51