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FOOD STAMP HANDBOOK

Handbook ________________FORMS AND INSTRUCTIONS 63-1230 (Cont,) 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 CA 8 (2/84) Stare of Caitlornia Department of Social Services Health and Weitare Agency STATEMENT OF FACTS FOR ADDITIONAL PERSONS (Supplemental Application for Food Stamps and Request for Cash Aid} COUNTY USE ONLY INSTRUCTIONS: Use this form to tell us about a new person in the home. If you need more space 10 feASE NUMBER answer the questions, attach another sheet of paper. SMT RERRE ff you racelve Cash Aid, and you want aid for the new person, this form must be completed by the adult caretaker relative who is now receiving aid. The new person may compiste the form unless it ig.a child, fot sual Food Stamos and Cran we | Grove For Food Stamp housshoids, which do not receive Cash Aid or da not want Cash Aid for the new person oe this form may be completed by a household member, an authorized representative or the hew person. SEIS | Specity wpe of . Wf you receive Food Stamps, answer questions (7) through 32 B | variication and | & Sei3 2 you receive Cash Aid and you want Cash Aid for the Person, answer quastians wSle_) wmevewes ie 4) through and through a), 3 : Fi aa # Hf you reaiva Food Stampe and Cash Aid, and you want Cash Aid far the new person, answer ail the i ‘|g ae ag : 3 questions. = ieee ine go PLEASE PRINT IN INK Ha ai 3¢ ee 33] ye @ Name at Parson Completing Form (First, Middle, Last) g8\Ss rs Bel» 3a 3 7 7 ; 7 Seles |S8/88) § Bigg Bit (QD List all new persons in ine home, including @ newborn, eu (aad s =) af od Person 1 Firat Name Middie Last Sociat Security Number ‘Birthdate Sen (Circle) M_oF Peruan 2 First Name. Middte Last Social Security Number Birthdate Sex (Circle) ME Anewer the following questions for aach new person, C1 ora 2e6-¢ Har he/she applied tor or raceived benefits in the st, such as: AFDC, Food Stamps, @ Rapes Refugee’ tenirent Aeron” Emargency Assistencs ate? °° ves OO No if YES, complete section balow: Date Applied | Date Last Received Where (County and State} Type of Benefits: Person 1 Person 2 ig Parson Va U.S, citizen? Oves CT No is Person 2 a U.S. citizen? OD ves 0 No HNO, completa section betow and attach proof af alien status, Date Person s Perkan Have an Entered U.S. | inciviouat Sponsor? | _! YES. Neme of Sponsor Parson Eyer 0 No SAS — Other proof tapecity: CA 22 Parson 2 0 yer © No oe Oa @ | he/she related to anyone in the home? 20 O_O Person 1: D Yes C1) No if YES, axpl: jonshiptsi: 1. stepperen 0 cA 71 UAM) is he/she a veteran, the child of veteran or the Surviving spouse or surviving child 2.) stepparent =) 6471 WAM of a veteran? Dives Cl No if YES, check ALL the boxes which apply: CAS Dete ininated: ferson 1; O Vetersn (© Chitdota Veteran Surviving Spouse ©) Surviving Chitd ©) Disabted f O ves (No Parson 2; {9 Veteran ©) Chitd of» Veteran © Surviving Spouse Suryiving Chiid ©) Disabled I) 5 ves C No 3) is he/she attending schoo! or a training program? O ves © No ILYES, complete section below: rand [2 ¢ Date of Name of Schoo! or Training Program Aueadig ae FaouRtion School Anendence Parson 1 D ves O No Ors O canaa vee Ono Person 2 © yes 9 No 20 sO cana O ves 0 no (8) 8 he/she participating ine labor strike? Cl yes f] wo HYES, complete section baiow: Dave Person Went on Strike | Grogs Monthly income Earned From This Jab Belore the Sirke Person 1 s Person 2| * ‘ “A Social Becurity Number (SBN) is requirad by Section 402[aH25} of the Bocial Security Act for Cash Aid recipients and by the Food Stamp Act of 1977, es aenended by’ Public Law $7.88, for each toad Hamp household mamber, These SSNs ae required to ensure the accurste issuance of Cash Aid and Food Stamp benefits to ipible individual va used in computer matching to prevent duplicate participation, to check the identity of individuais, to make changes and for program feviewas end pudl 19 provite an SSN will reeult in program iogtighbility tor the individual for whom the SSN is not rovided, CA 8 (2/84) AFDC ‘RCA-ECA Food Stamps Required Form - No Substitutes Permitted Page lots CALIFORNIA-DSS-MANUAL-SS Issue 627 Issued. 2/15/84 -

(MANUAL LETTER NO. 84-13) (0/7