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FOOD STAMP HANDBOOK
Handbook | ___________FORMS AND INSTRUCTIONS _ ~-83:1230 (Cont)
63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230
DFA 285-A2 (12/83)
G8) INCOME COUNTY USE ONLY
A WAGES JOOCUMENTATION GUIDELINES Complete this section for each person with # full or pert-time job. Complete even ¥ tha job has recently stopped or if a {Verify all income andlist type of new job was recently started and wages have not yet been received, if a member has mare than one job, list each | documentation viewed. Note job separately. include mambars who receive income from work study, CETA, WIN or eny ather training pragram. For Note dates al ail pay stubs your interview, please bring pay stubs or other proof of wages.
viewed. 4} How Often Paid v A x Zs eo on NAME OF WAGE EARNER NAME OF EMPLOYER ‘S oe Ss c Ed, LESS oat io oi SIE S/O *
1 2. 2, 4. 8. SELF-EMPLOYMENT — fs anyone in your household setf-employad? O ves O No H YES, who?
You must provide proof of seif-emplayment costs and income. €. OTHER INCOME Hes anyone received income trom any of the sources listed below? Complete even if income has recently stopped or if
anyone has applied for or expects to recaive income from any of these sources, Check each item YES ar NO. H YES, compiate the additional information needed, For your interview, bring praot of income far which you have checked YES below,
ie eo Lv} How Often Received é HOUSEHOLD MEMBER 3 Ke y A Leet % SOURCE OF INCOME (Vi (vil WHO RECEIVES SSE OS HBB E EY & OM AS SED EAE EY Cs af : Yee No THIS INCOME Oe LES EES ner Ay T. AFDC (Aid to Famities with
Dapendent Children) or RCA/ECA (Retugee/Entrant sh Assigtance.
2. Socia} Security: Blue/Green Checks
3. SSI (Supplemental Security income} « Gold Checks
4. GA {Ganarai Assistance) or GR (General Aeiief}
oFa jo jo jo OO jo jo jo
&. VA (Veterans Benefits}
6. VIB or Dig {Unemployment or Disability insurance Benefits) or Worker's Compensation
i] [ae
7. Pansions or Retirement income 8. A. Grants, Loans, Schotar-
ships, for schoo B. Tuition, Feas 6.
qv
oO a
8. Child and/or Spousal Support
im
oe fo ja goya |o jo
10, Money from other persons {other than loans}
11, Loans
12. Gross income from Property
19. Other ispecity)
.
COUNTY USE ONLY
Separate Househoid Eligible for Separate Grogs income Tes: Gross income Eligible: income Test Household Status:
Household Size
O ves Gio OwWea Household Size Q.¥es CNo
Gross Monthly income $ ._. Gross Manthiy Income §
Pege Jol 5
CALIFORNIA-DSS-MANUAL-SS Rev. 1349 replaces issue 2174 Effective 2/15/84
{MANUAL LETTER NO. 84-13} (23 &