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FOOD STAMP HANDBOOK FORMS AND INSTRUCTIONS _

§3-1230 (Cont) _ Handbook

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

DFA 285-A2 (12/83)

DEPENDENT CARE: Does anyone pay for someone to care for a child or disabled adult so CD Tar g am Gar Gonk aaeamayee pay for somneare job? D ves No COUNTY USE ONLY Ht YES, complete the following: TRAME GF PERSON PROVIDING THE CARE WHO FRYET HOw mig" [aow OnE (8) HOUSING Costs Complete the amount and how often you are billed for each of the housing costs you have HOUSING COSTS AMOUNT HOW OFTEN? | Verity all housing costs. A, Rant 8 B. Mortgage Payment 8 G._ Property Taxes iif not included in mortgage payment) 8 2. insurance On Home [if not included in mortgage payment) $ E__ Other Housing Costs (specify! : Total Housing § UTILITIES Client Elects: Check the box for each utility cost you pay and list the amount you are billed and how aften you ars billed, Youmay | [ Actual C) SUA request that the state standard utility allowance be used to compute your benefits. If your utility bitis are higher Verify client utitiies. then the state standard utilitystlowance, you may receive more tood stamps. Bring verification for any amounts listed ” below. UTHITIES Ama) AMOUNT HOW OFTEN? A, Gas or Fuel (for heating or cooling) BOs . B. Stectrigity tfor heating ot cooling) O_o is GC, Water D mie D. Sewage of) Is E, Garbage or Trash Oo Ole E,_ Telephone (basic rate) OO fe G. Gas or Electricity or Other Fuel for cooking! O Fis H. installation of Unvties oo is L_Dthar {specity| Oo is Total Utilities & oes anyone pay or help you pay any of the housing oF utility bills you have lied in 18 or 19 above? : D Yes (3 No | gua prorated: H YES, explain: D ves O no 1s anyone living in the home @ farmworker whe & currently away from his/her own Exempt from retrospective budgeting: BD Frome to were orto me ea D Yes (No { —Smbi tom revrospective Pucgetng: YES. who? O yee 0 No The jaw requires that information on ethnic origin and primary language be collected. However, the ETHNIC ORIGIN information will not stfect your eligibility for food stamps. If you do not wish to complete this section the WH BB AP eligibility worker wilt make this judgment. 1 2 3 4 My janguage is [check one box ontyi: [If you can speak My ethnic group is (check one box only}: and understand English, check English.) ALF 5 7 WH [3 White (not of Hispanic origin) & © Engiish F (© Filipino (Tagalog) Hw 0 Hispanic sp Spanish 5 © Sign PRIMARY LANGUAGE: B 0 _Binck {not of Hispanic origin} © © chinese © © Other (specify) ESP CH AP ©) Asian of Pacific islander VO Vietnamese 7 ro 2 Al 0 American Indian or Alaskan Native voF s 0 Fe © Filipino 3.4 ~=«6 66 cr) ; A. Maais on Wheels Program OD Yes © No Does anyone raceive meals from: B. Communal Dining Facility O vas © No

@4 You can authorize someone outside your Nouseholdto pick up your food stamps {or you or to use them to buy your food. # you would like to suthorize someone. complete below. NAME GF BoTHOREED REPRESENTANVE Poy TECEPRONE WuMaER

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CALIFORNIA-DSS-MANUAL-SS Rev. 1350 replaces Issue 2172 Effective 2/15/84

(MANUAL LETTER NO. 84-13) (p37