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FOOD STAMP HANDBOOK

63-1230 (Cont) FORMS AND INSTRUCTIONS -—Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 285-A2 (12/83)

ls anyone a disabled veteran, or @ disabled spouse or child of 6 Geceared nniwran? U'ves O No f COUNTY USE ONLY WYES, who? Does anyone purchase of prepare meals separately from others in ihe home? O Yes CY No HYES, who? 's anyone age 60 or older and unable to purchase and prepare meals separately becalse oladisability. () Yes CL No Separate houssholdt YES, who? Dives © No ay is anyone @ student 18 or aver who attends college or career yraining? O yes O No ILYES, complete the following: ; NAME OF STUDENT ‘SCHOOL GR PROGRAM ‘NO. GF GLASS NOURS PER WEBK/UNTS Bigibie Student “Nae OF FIUBENT BCHGOU Oh PROGRAM NO. GF GLASS HOURS PER WEEK UNTTE 1 O ves O No . 20 yes © No @ ROOMERS AND BOARDERS Househaid Elects ROOMER A.. Boss anyone pay yau for meals and/or a room? Hf YES, complete the following: Oliyes © No Paoamoe | wether NAME HOW MUCH? WOW OFTEN? TWO. OF MEALS PER DAY 1, 0) wees 0 toom EF pom! 8 Wane HOW MOCK? HOW OFTEN? | NO. OF MEALS BER Day 2. ©) Mesio Croom C) som} 6 8. Do you pay someone aise for meals and/or a room? Ht YES, complete the following: O Yes C No Tame WOW MCR HOW OFTEN) | NO. OF MEALS PER DAY 1. Meo £1 pcom O) son! 6 Wane How MUGRT HOW GFIEN? | NO. OF MEALS PER DAY . ©) meats £) room 0) son} § G3 INSTITUTIONS! Do You currentiy live in one of tha following Inaltutions? Orug/aicohol rehabilitation center QO Yes G No Shelter for battered women Q Yes No Federally subsidized housing for the elderly (J Yes No Other © Yes £1 No Usensed group home for the disabled/blind [© Yes O No Eligible Institution if YES, to any of the above, give name of hame/center: O ves ONo Does anyone who is nat a U.S, citizen have a sponsor? O ves 1 No if YES, who has # sponsor? (3 RESOURCES DO NOT COMPLETE TEM 15 IF EVERYONE IN THE HOME RECEIVES AFDC, A. Boos anyone haye any of the resources listed below? Check each tem YES or NO. H YES, compiete the sdditional iniormation needed. Do net inciude your home, household goods, cash vaiue of IN insurance polices or personal items (baoks, clothes, ste.), (itl Houschold Member | Current | Amount | paste wa) Yee No} Who Has This Resource Vaiue, Owed co Hf axa 1,__ Checks or money (at home or sisgwhere! 00 $ 2 2,_Checking account og 8 3... Sevings account/credit union account ao 8 4, Real estate (other than home} Go & 8 5._Notes, mortgages, trust deeds, sales contracts CIO & if 6. Trust funds po 8 7.__Stocks, bonds, certificates oo 8 8. Pension funds isnecify) oo 6 9. _ Other (specify) oo 8 $ 8. Does anyone own any cars, trucks, boats, traliers, vans. campers, motorcycles or other vehicles? O ves © No i YES, complete the following for each vehicle, Look at your registration to find the information for each vehicie Vehicis Vajuation you own, tEnter date of blue book issue ; Vehicle Vehicle Vehicle ar other documentation) Vehicles (1) 4 Vehicle Owner (2) Yeat/Class 13) Make and Modal Tota! Resources Estimated Value A Amount Owed Resource , Licensed (v“_box} Eves BD No Dyes No OG yes 5 tio Etigibi Oves CI No — mae ee oe = sino ae COUNTY USE ONLY - VEHICLES @) BiVatues { ) ¢ } Home, income producing ev or handicap? Minas BOG Under 84500 per table? — Exempy Line For H.H, use? ray Work, seek work, school, training?! inves Brcurm. If exempt and under 84500 STOP here; do not go to (B) Sree ate Page 2 of 4

CALIFORNIA-DSS-MANUAL-SS_ Rev. 1348 replaces Issue 2170 Effective 2/15/84

(MANUAL LETTER NO. 84-13) {55