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FOOD STAMP HANDBOOK flandbook FORMS AND INSTRUCTIONS
63-1230 STATE FORMS & INSTRUCTIONS
63-1230 CA 7 (2/84)
STATE OF EA@-Omm {atta UND ELPA astNEY
DeeaRrany OF SOCAL Kans
MONTHLY ELIGIBILITY REPORT For Cash Aid and Food Stamps Completa, sign, date and return this form AFTER the jast day of
THIS REPORT iS FOR THE MOWTH OF: .
Madi-Cai and/or Food Stamps may be delayed. decisased or discontinued,
© # you do net ATTACK proof of renaried mcome. your penatits may be discontinued. of discontinued.
© Gail your worker if you need help completing the form. Attach a separate sheet of apes it nesded,
Worker Phone:
@ You must complare this report ang rayuin it by the Sth of the month. if this feport is not received by the 11th af the month or is mcampiels. your Cash Aid, Cash-basad
Ht you do not ATTACH prast ot expenses, your bensiity may be dectensed
MOTE: if you or your family na longer want Cash Aid, Medi-Cal ar Fuod Stampe check this box compiate the signature block end tatu tha form by the due dats.
Reason and Typels) ot asistence: ifyau-recewe: rash aid ot. food:stamps, Jansiver(D)throuigh rece foot. ‘stamps, answer for: Leverynne: ‘receiv
0)
rotiremant, unemploymnant/ disability insurance, interest, workes's compensation, SSI/SSP {gold checks), child/spousal support, Joang, ‘Grants, tax refund, cash, gifts, fea housing/ wtilities, ate?
It anyone is saif- vad, list business
hy the $30 and 1/3 diaragard will nat be slowed,
(3). “Answer tar-Bueryone*in your hoasehold. if ‘you “receive ‘food: stamps, It-you-ito nat ‘tash said. “the. aided cehidred $ parents, :Stefiparents, ind “yaur*spouse <itin_youe home.
‘Dial anyera sacsive income, menay, or benafits is tha menth, such as: ‘sernings, training payments, earned incoma tux crudit, strike benefits, social security, railroad
CO", state the reason and type(s] of assistance no longer wanted,
(ves CJ wo
it YES, complete section below. ATTACH PAYSTUBS or other hroaf ot semings exch month. ATTACH PROOF for any other income only when it starts and whan it nal ‘on a separate shest of paper and ATTACH PROOF of income and axpanzes each month. {if yeu racers cash sid and you fail ta report pc ATTACH PROOF af earned income by tha 11th of the manth, the standard work expense, dependent care, aed whan digible far
ings Who Arceived income, Sources (If Earnings, Enter below dollar amounts and actual dates received. Nomar of] Murmber of Maney or Banatits? st Name of Employer) [ya before deducti Wetted || Works samings, enter gress amount before deductions. Hated, | Morag Tome maint oun Rioat Eraouant Traut i t 1 s a Daw tie tae Date Date ame Amount ‘Amaunt Amount Amount Amount Ll t + : z tae Cate tee iT tate Wana Arnaud “assure Fmaute ameunt Tosa ' 1 ‘ i ‘ Bets Date Bate ‘Date Cow
QA anyone pay for tee care ots child ar dinabled adult ao thet someone f the home cull pe is work, training we look for a jel? Jt YES. complete beiow and ATTACH » racsiot for each person receiving care.
C7 ves Co
Who feceivad Care? Cost of Care Who Recsived Care?
Soar of Care
3 3
$ +
6) p) ®
~ ig as
Dig anyone move into your home linciuding a new born], move Ut gat married, of dia?
Did snyane becume diasbled ot recover tram a disability? Did anyone etart rafies, nse, quit or change & j0b/ training, at go on strike?
Did snpene atart_ ston ot change school ur coliugel
9) Bis anyone receive, buy, sail at give away any property such @D wei houte. land, _metor Samper, best atc.)
the change. H property change, give valua of iem,
Oo ido po (i cc oe
if YES, to any of tha changes, give name of person, date of chenge and axplain
COUNTY USE ONLY EW, FRITIALS GATE:
GA T (2/84) AFOC/FOQOD STAMPS . Required form Yo Subsirures Permtiey.
Issued 2/15/84
CALIFORNIA-DSS-MANUAL-SS issue 625
(MANUAL LETTER NO, 84-13) le (7
83-1230 (Cont.)