Form SOC 453 at a glance
What it is: Cash Assistance Program for Immigrants (CAPI) Statement of Household Expenses and Contributions, from the California Department of Social Services.
Who signs: Sign as the Applicant/Recipient or Authorized Representative and write the Date. If you pay expenses to another person in your household, the head of household must review and sign this form.
The applicant/recipient must complete this form when applying for CAPI and at every redetermination.
A filled-in Form SOC 453 example: a recipient who rents and lives alone
How to fill out Form SOC 453, box by box
Name, case number and telephone
Write the Applicant's or Recipient's Name and the Case Number.
Write the Telephone Number and the Message Telephone Number.
Addresses
Write the Residence Street Address.
Write the Residence City, State and Zip Code.
Write the Mailing Street Address if different than your residence address.
Write the Mailing Address City, State and Zip Code.
Are you homeless?
Mark Yes or No for Are you homeless? "Homeless" means you do not have a permanent residence (such as temporarily staying with friends/family or sleeping in a shelter or car) and you do not live in an institution. If Yes, please skip to Part C.
Part A: Living arrangements
A household can be one person or multiple people. Members of a household share a common living space and combine money to pay for household expenses (such as rent, utilities, and food).
1. What date did you move to your address?
2. How many people live in your household (including yourself)? Write the number.
3. Do you live in a medical facility (e.g., hospital or skilled nursing facility)? Mark Yes or No.
4. Do you live in a residential care facility/assisted living facility? Mark Yes or No.
5. Does a relative, conservator, or legal guardian provide you with personal care and/or supervision to ensure your health and safety? Mark Yes or No.
Which of the following applies to your living arrangement
6. Which of the following applies to your living arrangement (choose only one)?
OWN: skip to Question #20.
RENT-LIVE ALONE OR ONLY WITH MY SPOUSE AND/OR MINOR CHILD(REN): skip to Question #20.
RENT-LIVE WITH OTHERS: continue to Question #7.
DO NOT RENT, BUT I CONTRIBUTE MONEY: skip to Question #16.
DO NOT RENT, AND I LIVE HERE FOR FREE: skip to Question #16.
Your landlord
7. Write the name, address, and phone number of your landlord.
8. Does your landlord charge you rent? Mark Yes or No.
9. Would your landlord ask you to move out if you stopped paying rent? Mark Yes, No or Unsure.
10. Would your landlord continue to hold you responsible for back rent if you were evicted for nonpayment of rent? Mark Yes, No or Unsure.
11. Do you and your landlord make decisions together regarding home repairs, improvements, and daily activities (e.g.,food purchases, TV cable, phone service, etc.)? Mark Yes or No.
12. Are any of the bills for the place where you live in your name? Mark Yes or No.
13. Do you and your landlord combine money for any household expenses? Mark Yes or No.
14. Do you have access to only part of the residence? Mark Yes or No.
15. Do you have a bedroom, cooking facilities, or a bathroom for your exclusive use? Mark Yes or No.
Your food
16. Do you buy most of your own food? Mark Yes or No.
17. Do you store your food separately from the rest of the household? Mark Yes or No.
18. Do you prepare or eat meals separately from the rest of the household? Mark Yes or No.
19. Would you like information about how to access food resources in your area? Mark Yes or No.
Public assistance and help to pay household expenses
20. Do all other household members receive some type of public assistance such as CalWORKs, BIA, SSI/SSP, VA pension, CAPI or General Assistance/General Relief? Mark Yes or No.
21. Do you or your spouse get help from anyone to pay for food, rent, mortgage, property insurance, utility bills, or other household expenses? For example, check "Yes" if a family member, friend, or third party gives you money to pay for those items. Mark Yes or No.
Item #1 and Item #2, who pays and the monthly amount
If you answered "Yes" to Question #21, please list the item paid for, who pays for it, and the monthly amount paid for it.
Do not list food stamps (such as CalFresh) OR housing subsidies (such as HUD/Section 8).
For each item, write who pays for this item (Name, address, and phone number).
Part B: Total household expenses
Do not complete this section if you live alone or only with your spouse and/or minor child(ren).
23. Please enter the average amount that your household pays each month for the items listed.
Enter the full monthly rent or mortgage, the cost of food for everyone in your household, etc.
Write in the total amount paid on behalf of everyone who lives in your household, including yourself, spouse, child(ren), and all others.
Only list the household expenses paid by your household.
Do not list any of the expenses of others who share your residence, but who are not part of your household.
Monthly food cost for entire household: if you answered "Yes" to Question #16, please enter zero.
If you pay rent, does it include all utilities? Mark Yes or No.
Your cash contribution
24. If you share household expenses with others who live in your household (other than your spouse, if any), write the amount that you (and your spouse, if any) contribute in cash each month.
If you live alone or just with your spouse (and/or child(ren) under the age of 18), please write "0".
25. What date did you start contributing the amount you listed in Question #24? Write the date (month/day/year).
Part C: Signature
Under penalty of perjury under the laws of the State of California, you declare that all answers that you have given and all statements on this form are correct and true to the best of your knowledge.
Sign as the Applicant/Recipient or Authorized Representative and write the Date.
Write the First Witness Signature (If marked with an "X") and the Date.
Write the Second Witness Signature (If marked with an "X") and the Date.
Write the signature of the interpreter or person completing the form on your behalf, and the Relationship.
Head of household
Head of household is someone in a shared household who is primarily responsible for household expenses and has ownership interest or rental liability.
This section does not apply if you're the only person in your household, or if you only live with your spouse and/or minor child(ren).
Signature of the Head of Household: a declaration, under penalty of perjury under the laws of the State of California, that all the information regarding total household expenses and the CAPI applicant's/recipient's cash contributions is correct and true to the best of knowledge.
Sources
[1] Form SOC 453 (8/22), Statement of Household Expenses and Contributions, California Department of Social Services (the Official source link on this page).