Page 56

Official source

63-1230 (Cont.) __.

"FOOD STAMP HANDBOOK FORMS AND INSTRUCTIONS _ Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

€3-1230 DFA 285-D (12/83}

WORKSHEET FOR CH

ANGES AND OTHER DOCUMENTATION

PART 4 — RESOURCES

2. Additional Resourses {specify} a,

. Subtotal (J1 + t2a + J2b + 2c} 4, Resources Soid, Traded or Given Away ispecity} a.

§. Subtotal (4a + Jab + J4c} &, Currant Resources (13 - J)

7, Resource Eligibia?

DOCUMENTATION i, MOTOR VEHICLES VYehicie {i} Vehicia (2) 1. Vehisie Owner Yoar/Cines Make and Model Estimatad Value Amaunt Owed 8 ont Sie ara senses Licensed? yes 0 No 0 Yes D) No excess or Gauity vaius, For unljoansed vehicion 2. Vaiue Count ine equity value. 3. Excluded oa home, income producing or oO Oo i= ol vefves i i)) ti) transport handicapped? Yas No Yas No Fay, ‘sinus 4, Under £6560 pec trie? Ll ves CI no | Cd ves Clue (i ory §. Exempt - Vise For noursngid user | Eve Eno | Pdves Tne ; For work, to seok work, ar school oF raining? im Yes C] No C Yes C] No Creumocence if exempt and under #4500 STOP here: do not go to &. stor J. RESOURCE ELIGIBILITY (Nonexempt Resources Only Desr™ on 1, Previous Month's Resources € 6

PART § — INCOME COMPUTATIONS

SELF-EMPLOYMENT

1. Gross income from Self-Empioyment

2. Expenses

3. Total Nonexempt income from Seif-Employment Feit! por ip ploy

Hf averaging saif-emplayment income go ta K7. If

adjusting a previous average, continue to K4.

4, Adjustment to Gross income

6, Adjustment to Expenses

Adjusted Sei-Employment incoma (K3 + Ké + KB!

6. 7. Monthly Seit-Empioymant income (K3 or K6 5 number of months incame covers)

EDUCATIONAL GRANTS, SCHOLARSHIPS AND LOANS

4. Income fram Grants, Schoterships or Loans 2. Tuition sad Mandatory Fees

3, Total Nonexempt Bducational income (L1 - L2) 4

+ Monthiy Income from Grante, Scholarships ot Loans (L3-> number of months income covers}

Truanee Monin

PART 8 — REPORTED CHANGES (Gther than the CA 7 or OFA 377.5}

Type of Change

Date Change Occurred id

Date Change Reported Md

EW initisis

CALIFORNIA-DSS-MANUAL-SS_ Rev. 1368 replaces Issue 2191

Effective 2/15/84

(MANUAL LETTER NO. 84-13) fy 4

Page 56

Official source

63-1230 (Cont.) __.

"FOOD STAMP HANDBOOK FORMS AND INSTRUCTIONS _ Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

€3-1230 DFA 285-D (12/83}

WORKSHEET FOR CH

ANGES AND OTHER DOCUMENTATION

PART 4 — RESOURCES

2. Additional Resourses {specify} a,

. Subtotal (J1 + t2a + J2b + 2c} 4, Resources Soid, Traded or Given Away ispecity} a.

§. Subtotal (4a + Jab + J4c} &, Currant Resources (13 - J)

7, Resource Eligibia?

PART § — INCOME COMPUTATIONS

SELF-EMPLOYMENT

1. Gross income from Self-Empioyment

2. Expenses

3. Total Nonexempt income from Seif-Employment Feit! por ip ploy

Hf averaging saif-emplayment income go ta K7. If

adjusting a previous average, continue to K4.

4, Adjustment to Gross income

6, Adjustment to Expenses

Adjusted Sei-Employment incoma (K3 + Ké + KB!

6. 7. Monthly Seit-Empioymant income (K3 or K6 5 number of months incame covers)

EDUCATIONAL GRANTS, SCHOLARSHIPS AND LOANS

4. Income fram Grants, Schoterships or Loans 2. Tuition sad Mandatory Fees

3, Total Nonexempt Bducational income (L1 - L2) 4

+ Monthiy Income from Grante, Scholarships ot Loans (L3-> number of months income covers}

Truanee Monin

PART 8 — REPORTED CHANGES (Gther than the CA 7 or OFA 377.5}

Type of Change

Date Change Occurred id

Date Change Reported Md

EW initisis

CALIFORNIA-DSS-MANUAL-SS_ Rev. 1368 replaces Issue 2191

Effective 2/15/84

(MANUAL LETTER NO. 84-13) fy 4