Page 12

FOOD STAMP HANDBOOK 83-1230 (Cont) ——-FORMS AND INSTRUCTIONS ___ aan Handbook 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 CA 8 (2/84) Does he7she own of. ighe/she bi an it ty, has: @ house, land, buildings, eic.7 @ Wes rtomolate soci beige wd MY FeAl Proper, Sue ee ake O Yor O'No | county use ONLY Tw Una Balance Sigex Type of Property Address “Location mena mt] "Owed | Value | Name of Mongage Company fe ychanl Parson 1 5 s Person 2 § 8 (0) dows he/she have any of the following resourcas? Check each Nam. YES, exolain below, Resource Parson 1 | Person 2 Resource Parson {| Person 2 Frecks of Money al Chves O nol ChyesO na} Trust Funds Cee Onell] ver Ono Ghecking/Savings/Cradit Union Cl vee F) No} ChvarD) not Stocks, Bonds, Certificates Giver Onell vee Cle Hotes. Mongages, Trust Deeds, [Chves 2 vc] Cl ves Nel Other ispecity below) Chios CiefSh vot Ce ones Type of Resource Owner Current Vaiue Location (Home, Bank Address, Etc.} Account Number | Exemo! & 8 Date Registration $ and

io) Does he/she own ar use or is he/she buying any motor venicias, auch as: a car, Iruck, boat,

Records Viewad,

Name of Empioyer

(before deductions} | ‘Waskly, Monthly, £16.) in Month fee

trailer, van, camper, motorcysia, etc.? O yes (© No {{ YES, complete section below: License Number and Amount of Last Owner Year, Make, Modal State of Registration License Fee | Balance Owed Vehicle Valuation Person 1 : 8 G te Person 2 $ 8 a6 is he/she employed? Ti ves O No If YES, complete section below, Attach paysiubs ot other proof of earnings. If he/sha is actf-employed list business expenses on a separate sheet of paper and attach proof of income and expenses. Gross Pay How Often Paid [Number of ‘Gheck enue OF Tews}

amber of ‘ays Worked [Roves Worked

‘Moot.

in Hexsmpt] Pay Stubal Orhee

tt YES, complete section below and attach proot of the income.

Porson 1 8

Person 2 $ Doss he/she receive or expect to receive any other income, such as; Social Security, Unemployment’ Digablity insurance, Child/Spousal Support, Veterans Benafits, Free Housing, Free Utilities, Gte.? Eyes © No

How Often Received} Date Last | Date

‘Expected [Check Soecify Verification | Type of income Amount NWoekly. Moniniy fie) | Received | wBeain, ro | Person t 8 Person 2 8 Does he/she pay someone io care for a chiid or disabled adult so he/she can go to work OF training of look for work? OD Yes © No ICYES, complete section below and attach recaipts, Saco Who Received Care? Who Provided Care? ‘Amount (ee Tan een FO Person + 8 Person 2 5 ‘nawer questions (6) through f8) only Hf you receive food stempe. Does ha/she receive food from a Food Distribution Program operated by an Indian Reservation? Parsont Yes O No if YES, which reservation? Person? O Yes DNo i YES, which reservation? ® Does he/she purchase or prapare meals separately from others in the home? Perront Cl Yes O No Person? Cl Yes O) No @ is he/she age 60 or sider and unable to purchase and prepare meals separately because of a disability? Persont Ol Yes ( No if YES, does he/she want to be 4 separate food stamp household? O ves © No Person2 Cl Yes © No If YES, does he/she want to be a sapsrata (ood stamp household? Dyes © No Does he/she pay you lor meals andor a room? O ves (No ILYES, complete section beiow: REARS ETRE How Much? [How Otten? No. of Meais Par Day | posse [HH Memoer| Roamet Person 1{ DO Maasis (Room [9 Both fs. Person 2| O Meats (Room ) Both [s I Answer question (9) if you receive Ceah Aid. Hf you do not receive Cash Aid, skip questions fe) through 9) and complete the certification section. Page 2 of 3

CALIFORNIA-DSS-MANUAL-SS

Issue 628

yd

(MANUAL LETTER NO. 84-13)

Issued 2/15/84

VET AVTrE=S=AE SEPP Tan Pa: RRO