Page 48

83.1230 (Cont)

FOOD STAMP HANDBOOK __FORMS AND INSTRUCTIONS.

Handbook i

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

63-1230 DFA 285-B (12/83)

WORKSHEET FOR CHANGES AND OTHER DOCUMENTATION

PART 4 —- RESOURCES DOCUMENTATION K, MOTOR VEHICLES Vehicle (1) Vehicie (2) 1. Vehicie Owner Year/Class Maks and Modal Estimated Value Amount Owed 5. Fer ger aed Pues Licensed? fl yes No Byes 0 No excess oF equily value. for uniicensed vehicias 2, Value count the eauty value 3. Excluded as home, Values | ti) Oy eee Pree ee | Llves Edo | Elves [lio Taw 4, Under 64500 per tabie? im Yes i_ No. CI Yes im No esto 5, Exempt + Gren For household use? O Yes ia No i Yes O No. ew Foran femme | dyes Etno | Cd yen Cdn [ities {{ exampt and under $4500 STOP here: do not go to 8. Sok L. RESGURCE ELIGIBILITY (Nonexempt Resources Oniy) | Ment. Monn 1. Previous Month's Resources $ s 2. Additional Resources {specity| a b. o 3, Subtotal (L1 + L2e + L2b + £20} é 8 4, Resources Sold, Traded or Given Away (specify) a $ $e b, e §. Subtotal (L4a + L4b + Lao} $ a [ee 6. Current Resources (L3 - LS} ‘ 8 ._Resource Eligible? Co ves Cl No O Yas (a No PARTS — INCOME COMPUTATIONS M. SELF-EMPLOYMENT Monn foe 1. Gross income from Self-Employment 8 8 2, Expenses — 3. Totai Nonexempt income trom Self-Employment . {My - M2} 8 cere ene 8 eee Ht averaging self-employment income go to M7, If adjusting a previous average, continua to M4 4, Adjustment to Gross income § $ 6, Adjustment to Expenses 6, Adjusted Saif-Employment Income (M3 + M4 + MB . 8 7. Monthly Self-Employmant income (M3 or M6 = number of months income covers} Be, 6 N. EDUCATIONAL GRANTS, SCHOLARSHIPS avance iuance AND LOANS 1, Income trom Grants, Scholarships or Loans 6 st 2. Tuition and Mandatory Fees nee 3. Total Nonexempt Educational income (NJ - N2} [OS ea 4, Monthly income from Grants, Scholarships or Loans {N3<-number of months income covers} $ 8 erect

PART 6 ~ REPORTED CHANGES

{Other than the CA 7 or DFA 377.5)

Typa_of Changs

Date Change Occurred

Date Change Reported,

EW initial:

Rev. 1360 replaces

_ issue 2182

CALIFORNIA-DSS-MANUAL-SS

Effective 2/15/84

TRA ARIEDIATL

rer BPA OA 4