Capi Form Soc 453 – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI) STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS

APPLICANT’S/RECIPIENT’S NAME

APPLICANT’S SOCIAL SECURITY NUMBER

SPOUSE’S NAME

SPOUSE’S SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS:

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

MESSAGE TELEPHONE NUMBER

PART A - LIVING ARRANGEMENTS: Statement of the CAPI applicant/recipient and spouse

1.	What date did you move to this address?	______________________________________________
		(MONTH/DAY/YEAR)
2.	How many people live in this residence?	(Count yourself, your spouse, children and all others.)	_________
3.	Do all other household members receive some type of public assistance such as CalWORKs, BIA, SSI/SSP, VA			■ Yes	■ No
	Pension, CAPI, or GA/GR?
4.	Do you (or your spouse) own or are you buying the home you live in?			■ Yes	■ No
5.	Do you (or your spouse) rent the home you live in?			■ Yes	■ No
6.	Are you (or anyone who lives with you) the parent or child of the landlord or landlord’s spouse?			■ Yes	■ No
7.	a. Does any organization or person who does not live with you help you (or your spouse) pay for food, rent,			■ Yes	■ No
	mortgage,property insurance, utility bills, or other household expenses? If yes, answer 7b.
	b. Item: _________________________ Contributor: ___________________________________		Monthly Amount: $ _____________
8.	Do you buy all your own food?			■ Yes	■ No

PART B - TOTAL HOUSEHOLD EXPENSES: Expenses paid by entire household

9. a. Please enter the amount the entire household pays each month for the following items.

Write the total amount paid on behalf of everyone who lives in this residence, including yourself, spouse, children, and all others. Enter the full monthly rent or mortgage for the house or apartment, cost of food for everyone, etc.

	Food (unless you buy your own food separately): ___________________	Gas: ___________________
	Rent or mortgage: ___________________	Electric: ___________________
	Property Insurance: ___________________	Water: ___________________
	Property Taxes: ___________________	Sewage: ___________________
		Garbage: ___________________

b.If you share household expenses with others who live with you, write the amount you and your spouse contribute in cash each month. $ ______________

PART C - SIGNATURE: If the CAPI applicant/recipient pays household expenses to another person who lives in the same residence, or shares expenses with a person who lives in the same residence, that other person (called “Head of Household”) must review this form, verify that it is accurate, and sign below.

CAPI Applicant/Recipient

I declare under penalty of perjury under the laws of the State of California that all answers that I have given and all statements on this form are correct and true to the best of my knowledge.

Head of Household

I declare under penalty of perjury under the laws of the State of California that all that all the information above regarding total household expenses and the CAPI applicant’s/recipient’s cash contributions is correct and true to the best of my knowledge.

SOC 453 (11/02)