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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)

Boes he/she want to receive Gash Aid? Person t: O Yes (]No if either person answers YES, complete questions through if both answer Person ?: Dyes (No NO. skip questions @G) through 8) and complete the certification section

QO it he-she is a child under age 19 compiate section below.

COUNTY USE ONLY

Child Neads Aid Dueto Parent's:

Mother's Name Father's Name {Check al! boxes which appiy} Deprivation Variication

Parson 1 Di Assence [2 incapacity 2) unemployment [ death

Person 2 (absence (2 incapacity [] Unemployment O death

Does he/she presently live in Cafifornia and intend to continue living here? Person? (J Yes ©) No Person 2 [3 Yes D) No

Does she wish to receiva aid because of pregnancy? ves O No if YES. compiete section below: Expected Date of Birth Father's Name Unborn Child's Father Is: (Chack atf boxas wivich apply) | preanancy Verification: Pregnancy Verification: Parson 4

Tavsent ©] incapacitated [J Unemploves [Deceased

i

Person 2 Dlarsent 0 incapecised ©} Unemployed © deceased 2 Has he/she quit or refused a job or reining in the last 30 days? Dives (Ne it YES, complete section below: Amount of Last | Cast Day of | Meza Wenci” | Name and Address of Employer? Reason far Leaving Determination of Goad Pay Check [Joab/Training | use35'Bace Training Program: of Refusal Cause Reguired: Berson 11s 1 Doves © No Parson 2| § 2 Clyves CI wo Boos haraha Gwn of Use personal propery Which cost BY Wasi STOO for each Wem or are how warth at feast $100 each, such as: jewelry. equipment, instruments, livestock, etc.? Olives O No Do not list clothing, wedding rings. rugs, furniture, appliances, other househaid furnishings, IYES, complete section balow: Name of hem Date of Purchase | Purchase Price | Amount Owed | Net Market Value: Person 1 § 8 te Person 2 : ‘ 8 as GB) Has he/she sold, transferred oF given away ahy real or personal property within the lat 2 years?, Ol ves C2 No if YES. compiate section below: Name of tem Date Soild. Transterred or Given Awoy | Amount Received Parson 1 8 Person 2 8 QO) Does he/she nave any of the following insurance coverages: lita, burial, disability or mortgage? Dyes O No | Towcsv lt YES, complete section below: ws Name of insurance Company| Policy Number Parsons Covered {Names} | Premium Paid by (Nemell Amount Paid] > . OHC Code Person | 8 Enlored: Daw: Person 2 $ a Gp Does He/she have Health or hosphtalwation insurance, including inguiance pald Jor By an emplayer or absent parent, 2 oO such as; Bive Cross, Kaiser, Champus, atc,? Person Cj Yes O No. Person 2 [) Yes (No a Complete question @8 in the presence of your eligibility worker. faa) CHOP brochure and = : i fe 2g A Does he/she wam informetion about the Child Health Disability Prevention Program(CHBP), Family sRelerved Planning. Atcohol or Drug Abuse Counseling, past madical expenses and other special needs? O Yes (2 No Date 8. Doas he/she want CHDP Medical or Dental Services? : Dives O No B Diner services relerrel €. Does he/she want Family Planning Services? Ol yves O No Sy a nning into g

Ci Date referred:

~~ ; ” CERTIFIGATION eT mdersiand that failing to report jotormation or aisrepcesantation of fects far Cash Aid programs or Food Stamps can rewh in Mgt! prosecution with penahios

of 14 fiat, imprischment ar both. In the Food Stamp Pregram the panehisr can result in permanent disgueltication from the Program. fines up to #16.000 or dmgrisenmont for wp to 5 years,

© f understand that the information { have provided will be verified by local, state and feders! personnel. © / understand that my case may be selected for an additional review to ensure that my eligibility was determined correctly @ / declare under pensity of perjury that the above stalemants are true and correct

For Cash Aid programs, you and your sided spouse or the other parent of aided child(ren) living in the home must sign the form. For the Food Stamp Program, the hasd of household, a housahoid mamber of the household's authorized representative must sign the form.

Signature of Cash Aid Recipient or Caretaker Reletive and ‘or Food Stamp Housenold Mamber ]County Where Signed Date Signed

Bignature of Cash Aided Spouse or Other Parent of Gash Arded Chikiren County Whare Signed Date Signed

Signsture of Witness to Mark. Interpreter, or Oiber Person Completing Forin County Where Signed Date Signed

Page 3013

CALIFORNIA-DSS-MANUAL-SS Issue 629 Issued 2/15/84

(MANUAL LETTER NO. 84-13) b a |