Capi Form Soc 814 – Fill Out and Use This PDF

The Capi Soc 814 form is a vital document managed by the California Department of Social Services, specifically designed for the Cash Assistance Program for Immigrants (CAPI). This state-funded program provides financial assistance to non-citizen residents of California. It requires applicants to provide thorough information about their personal circumstances, immigration status, living arrangements, and financial resources to assess eligibility. If you or someone you know might benefit from this program, consider exploring the requirements more closely by clicking the button below to fill out the form.

Get Form Now Download PDF

Capi Form Soc 814 PDF Details

Navigating the intricate details of the CAPI Soc 814 form is an essential step for non-citizens residing in California who are seeking cash assistance. This form, integral to the Cash Assistance Program for Immigrants (CAPI), serves as a comprehensive statement of facts designed to assess eligibility for financial aid. It requires applicants to provide detailed information ranging from personal identification, marital status, and residency to income, resources, and immigrant status. What makes this form critical is its role in aiding those who, due to their immigration status, might not qualify for other federal assistance programs. Applicants are guided through various sections that help the State of California's Department of Social Services understand the applicant's living situation, health status, and financial circumstances. With space to elaborate on physical or mental health issues, living arrangements, and even details about one's sponsor, the form meticulously gathers information to ensure accurate assistance eligibility assessments. The requirement for clarity and thoroughness in filling out the form, along with the necessity for applicants to sign and date it, underscores the importance of accuracy and honesty in the application process. Additionally, the form's provisions for applicants to indicate any help needed in completing the form or obtaining required proof furthers its accessibility and user-friendliness.

Question	Answer
Form Name	Capi Form Soc 814
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	capi application forms, SSI, CAPI, CALIFORNIA

Form Preview Example

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

STATEMENT OF FACTS

COUNTY USE ONLY

CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)

CASE NAME

Instructions: CAPI is a State-funded program for non-citizens only. Please print your

answers clearly in blue or black ink. This application must be signed and dated by the applicant

and spouse (if applicable).

CASE NUMBER

If you need more space, use the "Remarks" section on page 6. Tell your worker if you need help

in getting proof or filling out this form.

WORKER

DATE RCD

Type of Application:

■ Couple

■ Individual

■ Child

■ Child with Parents

APPLICANT

a. First Name, Middle Initial, Last Name

DATE OF BIRTH

SEX

SOCIAL SECURITY NUMBER

LINKAGE

SSN

■ Male

■ Aged

__ __ __-__ __-__ __ __ __

■ Blind

■ Female

■ Disabled

b. Did you ever use any other names (including maiden name) or other

■ YES ■ NO

Social Security Numbers?

c.Other names and Social Security Numbers used:

RESIDENCE ADDRESS (NUMBER AND STREET)

CITY

ZIP CODE

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

CITY

ZIP CODE

(AREA CODE) HOME PHONE

(AREA CODE) WORK PHONE

(AREA CODE) MESSAGE PHONE

PERSON WITH WHOM TO LEAVE MESSAGE

e. Do you intend to remain in California?

■ YES

■ NO

a. Do you have any physical or mental health problems or are you

YOU

YOUR SPOUSE

blind? (For example: high blood pressure, heart problems,

■ DAPD Referral Completed

diabetes, arthritis, osteoporosis, vision problems, depression, etc.)

■ YES ■ NO

■ YES

■ NO

■ Disabled

If yes, explain briefly:

■ Sponsored Deeming

Date Problem(s) Began

Describe Health Problem(s)

■ SSI Referral Completed

You

Your Spouse

MARITAL STATUS

Spouse

3 a.

Are you married?

■ YES

■ NO

LINKAGE

SSN

■ Aged

(Go to #4a.)

■ Blind

b. Spouse’s Name (First, Middle Initial, Last)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

■ Disabled

__ __ __-__ __-__ __ __ __

Did your spouse ever use any other names (including maiden name) or

■ YES

■ NO

other Social Security Numbers?

d.Other names and Social Security Numbers used by spouse:

e.	Are you and your spouse living together?		■ YES	■ NO	Spouse eligible?
					■ Yes ■ No
f.	Date you began living apart:	SPOUSE’S ADDRESS:

g.	Is your spouse applying for CAPI?		■ YES	■ NO

SOC 814 (11/02)

PAGE 1 OF 8

IMMIGRANT STATUS

COUNTY USE ONLY

Are you a United States citizen?

YOU

YOUR SPOUSE

If yes, go to end of application and sign your name.

■ YES

■ NO

■ YES

■ NO

Have you or your spouse (or former spouse) ever been in the

■ YES

■ NO

■ YES

■ NO

U.S. Military Service?

Are you lawfully admitted for permanent residence in the

■ YES

■ NO

■ YES

■ NO

United States?

Resident card on file?

Give the date of lawful admission for permanent residence.

MO.

DAY

YR.

MO.

DAY

YR.

■ YES

■ NO

______/______/______

c. Did any person, institution or group sponsor your entry

■ YES

■ NO

■ YES

■ NO

SPONSORED?

into the United States? If yes, go to #6. If no, go to #7.

■ YES

■ NO

Give the following information about your sponsor(s):

AFFIDAVIT OF

SUPPORT

You

■

SPONSOR’S NAME

ADDRESS

TELEPHONE NO.

Spouse ■

(

)

■ Form I-134

You

■

SPONSOR’S NAME

ADDRESS

TELEPHONE NO.

■ Form I-864

Spouse ■

(

)

You

■

SPONSOR’S NAME

ADDRESS

TELEPHONE NO.

Spouse ■

(

)

YOU

YOUR SPOUSE

Is your sponsor deceased?

VERIFIED

■ YES

■ NO

■ YES

■ NO

■ Deceased

Is your sponsor disabled?

■ YES

■ NO

■ YES

■ NO

■ Disabled

Are you being abused by your sponsor or his/her spouse?

■ YES

■ NO

■ YES

■ NO

■ Abused

If not lawfully admitted for permanent residence, briefly explain your current immigration status with the

INS Documentation

Immigration and Naturalization Service (INS):

on file?

YOU

YOUR SPOUSE

■ Yes

■ No

Through what date will INS allow you to remain in the

YOU

YOUR SPOUSE

United States? (If indefinitely, indicate.)

8What is your Alien Registration Number?

9What was your Port of Entry?

		RESIDENCY

10	Are you hiding or running from the law for a felony, attempted felony,		YOU		YOUR SPOUSE
	or a parole or probation violation?		■ YES	■ NO	■ YES	■ NO
	If yes, go to the end of the application and sign your name.		■ YES	■ NO	■ YES	■ NO
							U.S. Resident?
11	a.	When did you first make your home in the United States?	Date:		Date:		U.S. Resident?
11	a.	When did you first make your home in the United States?	Date:		Date:
							■ Yes ■ No
	b. Have you lived outside of the United States since then?		■ YES	■ NO	■ YES	■ NO	■ Yes ■ No
	b. Have you lived outside of the United States since then?		■ YES	■ NO	■ YES	■ NO
							■ Passport viewed and
	c. Give the dates you were outside of the United States.		From:		From:		■ Passport viewed and
	c. Give the dates you were outside of the United States.		From:		From:		copy on file
		(month, day, year)	To:		To:		copy on file
		(month, day, year)

12	a.	Within 30 days prior to applying for CAPI, were you	■ YES	■ NO	■ YES	■ NO	■ Month aid begins:
12		outside of the United States?	■ YES	■ NO	■ YES	■ NO	■ Month aid begins:
		outside of the United States?					_____________

	b.	Give the dates you left and returned to the United States.	Date left:		Date left:
			Date left:		Date left:
			Date Returned:		Date Returned:
			Date Returned:		Date Returned:

LIVING ARRANGEMENTS

13Check the applicable block to show where you live now:

■ House	■ Room (commercial establishment)	■ Nursing Home
■ Apartment	■ Mobile Home	■ Jail
■ Room (private home)	■ Residential Care Facility	■ Shelter for Battered Women
■ Hospital	■ Homeless Shelter	■ Other Institution

■Other (specify) _____________________________

14 a.		Do you need assistance in your personal care or hygiene,	YOU		YOUR SPOUSE		■ IHSS Referral
		(e.g., help with eating, dressing, bathing, taking medication,	■ YES	■ NO	■ YES	■ NO	■ NMOHC
		or moving about)?	■ YES	■ NO	■ YES	■ NO	■ NMOHC
		or moving about)?
							Cooking Facilities?
	b.	Do you have adequate cooking and food storage facilities	■ YES	■ NO	■ YES	■ NO	Cooking Facilities?
	b.	Do you have adequate cooking and food storage facilities
		available?					■ Yes ■ No
		available?					■ Yes ■ No

PAGE 2 OF 8

	LIVING ARRANGEMENTS (CONTINUED)			COUNTY USE ONLY

		YOU	YOUR SPOUSE
15 a. Do you and your spouse (if applicable) live alone?
15 a. Do you and your spouse (if applicable) live alone?		■ YES ■ NO	■ YES ■ NO

b.If no, give the following information about everyone who lives with you (or with you and your spouse):

Relationship

Sex

Date of

Receives Public

Public Assistance

Name

to you

Assistance

Includes:

Birth

or spouse

Yes

•

BIA

•

CalWORKs

•

CAPI

•

SSI/SSP

•

GA/GR

•

VA Pension

YOU

YOUR SPOUSE

16 a.

Do you rent, own or are you buying the place where you live?

■ YES

■ NO

■ YES

■ NO

■ Rental Liability/

Ownership Verified

If yes, how much is the monthly rent/mortgage payment?

$ ____________

SOC 453?

c. Does anyone who lives with you rent, own, or is he/she buying

■ YES

■ NO

■ YES

■ NO

■ Yes

■ No

the place where you live?

RESOURCES/PROPERTY

Exempt Vehicle?

YOU

YOUR SPOUSE

■ Yes

■ No

17a. Do you own or does your name appear on the title of any vehicle;

(e.g., cars, trucks, boats, motorcycles, motor homes, etc.)?

■ YES

■ NO

■ YES

■ NO

2nd Vehicle

Market

Description

Used For (Work,

Current

Amount

Owner’s Name

Value:

$ _________

(Year, Make and Model)

Medical Other)

Market Value

Owed

Encum-

brances: - $ _________

Equity

Value:

= $ _________

a. Do you own or are you buying any life insurance policies?

YOU

YOUR SPOUSE

■ YES

■ NO

■ YES

■ NO

b. Give the following information on each policy:

Policy #1

Policy #2

Owner’s Name

CSV?

■ Yes

■ No

Name of Insured

Amount: $ ___________

Name of Insurance Company

Policy Number

Face Value

Cash Surrender Value

Date Purchased

Loans Against the Policy

■ YES

■ NO

■ YES ■ NO

Do you (either alone or jointly with another person) own any:

YOU

YOUR SPOUSE

a. Life estates, or ownership interest in an unprobated estate?

■ YES

■ NO

■ YES

■ NO

b. Household or personal items with a resale value of over $500 ea.?

■ YES

■ NO

■ YES

■ NO

c.If yes, give the following information:

Owner’s Name	Item	Resale	Amount owed
Owner’s Name	Item	Value	on item
		Value	on item

		$	$

		$	$

PAGE 3 OF 8

20 a.

YOU

YOUR SPOUSE

Do you own or does your name appear (either alone or jointly) on any of the

following items either inside or outside of the United States?

YES

Cash (at home, with you, or anywhere else)

Checking Accounts

Savings Accounts

Credit Union Accounts

Certificates of Deposit

Notes

Bonds

Money Market Accounts

Stocks

IRAs

Other items that can be turned into cash

Give the following information for any “yes” answers in 20a.

Owner’s Name

Name of Item

Value

Name of Bank or

Account

Financial Institution

Number

21 a. Do you own any land, buildings or does your name appear on the title of	YOU	YOUR SPOUSE
ANY property either inside or outside of the United States, other than at the
	■ YES ■ NO	■ YES ■ NO
address where you currently live?	■ YES ■ NO	■ YES ■ NO

b.If yes, give the following information:

	Type of Property		Location of Property			Value

						$
						$
22 a.	Have you sold, transferred title, disposed of or given away any money or				YOU	YOUR SPOUSE
	property, including money or property in foreign countries, within 36 months
				■ YES ■ NO		■ YES ■ NO
	of this application filing date, and after December 14, 1999?			■ YES ■ NO		■ YES ■ NO

b.	If yes, give the following information:

		Current	Date of
	Description of Property	Market	Date of		Reason for Transaction
	Description of Property	Market	Transaction		Reason for Transaction
		Value	Transaction
		Value

	Name, Address, and Telephone Number of			Relationship to		Sales Price or Other
	Buyer or Person Who Received Property				Applicant	Agreement

					YOU			YOUR SPOUSE
23	a.	Do you have any money set aside for burial expenses?
23	a.	Do you have any money set aside for burial expenses?		■ YES		■ NO		■ YES		■ NO
				■ YES		■ NO		■ YES		■ NO

	b.	Owner	Description			Value	Date Set		For Whose Burial
	b.	Owner	(Type of Asset, Name of Organization)			Value		Aside	(Relationship)
			(Type of Asset, Name of Organization)					Aside	(Relationship)



					YOU			YOUR SPOUSE
24	a.	Do you own any cemetery plots, crypts, caskets, vaults, or urns?
24	a.			■ YES		■ NO		■ YES		■ NO
				■ YES		■ NO		■ YES		■ NO

	b.	Owner	Description			Value	For Whose Burial (Relationship)

COUNTY USE ONLY

Verified?

■ Yes ■ No $ _________

$ _________

Total: $ _________

Verified?

■ Yes ■ No

Sold for less than Market Value?

■ Yes ■ No

Date and

Transfer Verified?

■ Yes ■ No

Period of Ineligibility:

Beginning

date: _______________

Ending

date: _______________

Exempt?

■ Yes ■ No Amount over $1,500

________________

■Revocable

■Irrevocable

■Revocable

■Irrevocable

PAGE 4 OF 8

INCOME

COUNTY USE ONLY

25 a.

Have you received, or do you expect to receive income from

YOU

YOUR SPOUSE

any of the following sources?

Source

YES

Gifts/Support

Social Security

Veteran’s Administration (VA)

Supplemental Security Income (SSI)

Unemployment Benefits

State Disability

Workers’ Compensation

Other Pensions/Annuities

CalWORKs

General Assistance/Relief

Rental Income

Insurance Payments

Interest/Dividends

Alimony/Child Support

Verified?

Other Income

■ Yes ■ No

For each “yes” answer, give the following information:

$ _________

Person Receiving

Type

Gross Amount

How Often Received

$ _________

Total: $ _________

YOU

YOUR SPOUSE

26a. Do you receive or do you expect to receive any wages?

■ YES

■ NO

■ YES

■ NO

Verified?

■ Yes

■ No

If yes, give the following information:

Employer’s Name, Address,

Gross Wages

Dates of

Person Working

Paid:

and Telephone Number

Amount

How Often Paid

Employment

■ Daily

From:

■ Weekly

■ Bi-Weekly

■ Monthly

To:

■ Twice Monthly

■ Fluctuating

From:

To:

27 a.

Have you been, or do you expect to be self-employed in the

YOU

YOUR SPOUSE

current year?

■ YES

■ NO

■ YES

■ NO

Tax Return?

b. If yes, give the following information:

■ Yes

■ No

Type of Business

Last Year’s

This Year’s

Dates of Self-

Year of

Employment

Gross Income

Net Income (Loss)

Gross Income

Net Income (Loss)

Tax Return: ________

28	If you are under age 65 and disabled, do you have any special	YOU		YOUR SPOUSE
	expenses related to your illness or injury that are necessary for you to					IRWE?
		■ YES	■ NO	■ YES	■ NO
	work? If yes, describe in “Remarks” on page 6.
	work? If yes, describe in “Remarks” on page 6.					■ Yes	■ No

29	Are you currently receiving Food Stamps or have you recently applied	YOU		YOUR SPOUSE
		YOU		YOUR SPOUSE

	for Food Stamps?	■ YES	■ NO	■ YES	■ NO

PAGE 5 OF 8

Remarks: (Use this area to add to the information you have given on the previous pages or to give other information.)

YOUR AUTHORIZATION AND CERTIFICATION STATEMENT

I/We give permission to state and county agencies to check the information I/we have given on this form, and to ask my/our employer(s) for information about my/our wages. I/We understand that these agencies will compare information given on this form with records from other county, state and federal agencies to make sure the correct amount of benefits is paid.

I/We have read and understand my/our responsibilities.

I/We understand that anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth is committing a crime that can be punished under State law.

I/We certify under penalty of perjury that the statements given on this form are the truth as I/we know it.

YOUR SIGNATURE				DATE

SPOUSE’S SIGNATURE				DATE

WITNESS, IF SIGNED WITH AN “X”				DATE

SIGNATURE OF INTERPRETER OR PERSON COMPLETING FORM ON YOUR BEHALF	RELATIONSHIP TO APPLICANT	TELEPHONE NUMBER		DATE
		(	)
		(	)

PAGE 6 OF 8

Important Information - Please Read Carefully

REPORTING RESPONSIBILITIES

You must tell us about any change within 10 days after the month it happens. Failure to report any change within 10 days after the end of the month in which the change occurs could result in a penalty.

CHANGES TO REPORT

WHERE YOU LIVE:

●If you move.

●If you leave the United States for 30 days or more.

●If you are no longer a legal resident of the United States.

●If you (or your spouse) leave your household for a calendar month or longer. For example, you enter a hospital or visit a relative.

●If you are released from a hospital, nursing home, etc.

HOW YOU LIVE:

●If someone moves into or out of your household.

●If the amount of money you pay toward household expenses changes.

●The birth or death of any people with whom you live.

●If your marital status changes: You get married, separated, divorced, or your marriage is annulled or you start living together after a separation.

INCOME:

●If the amount of money (or checks or any other type of payment) you receive from someone or someplace goes up or down.

●If you start to receive money (or checks or any other type of payment).

●If you start or stop work.

●If your earnings go up or down.

HELP YOU GET FROM OTHERS:

●If the amount of help (money, food, clothing, or payment of household expenses) you receive goes up or down.

●If someone stops or starts helping you.

THINGS OF VALUE THAT YOU OWN:

●If the value of your total resources goes over $2,000 ($3,000 if you are married and live with your spouse).

●If you sell or give any things of value away.

●If you buy or are given anything of value.

YOU ARE BLIND OR DISABLED:

●If your condition improves or your doctor says you can return to work.

●If you go to work.

●If you stop or refuse any vocational rehabilitation services.

UNMARRIED AND UNDER AGE 22:

●If you are the parent of a child who receives CAPI benefits, you are to report if you or your child has a change in income, a change in marital status, a change in the value of anything the family owns, or if there is a change in residence.

●If the child starts or stops school.

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES OR YOU BECOME A CITIZEN OF THE UNITED STATES.

I/We understand my/our reporting responsibilities and agree to cooperate.

YOUR SIGNATURE

DATE

SPOUSE’S SIGNATURE

DATE

PAGE 7 OF 8

KEEP FOR YOUR RECORDS

Important Information - Please Read Carefully

REPORTING RESPONSIBILITIES

CHANGES TO REPORT

WHERE YOU LIVE:

●If you move.

●If you leave the United States for 30 days or more.

●If you are no longer a legal resident of the United States.

●If you (or your spouse) leave your household for a calendar month or longer. For example, you enter a hospital or visit a relative.

●If you are released from a hospital, nursing home, etc.

HOW YOU LIVE:

●If someone moves into or out of your household.

●If the amount of money you pay toward household expenses changes.

●The birth or death of any people with whom you live.

●If your marital status changes: You get married, separated, divorced, or your marriage is annulled or you start living together after a separation.

INCOME:

●If the amount of money (or checks or any other type of payment) you receive from someone or someplace goes up or down.

●If you start to receive money (or checks or any other type of payment).

●If you start or stop work.

●If your earnings go up or down.

HELP YOU GET FROM OTHERS:

●If the amount of help (money, food, clothing, or payment of household expenses) you receive goes up or down.

●If someone stops or starts helping you.

THINGS OF VALUE THAT YOU OWN:

●If the value of your total resources goes over $2,000 ($3,000 if you are married and live with your spouse).

●If you sell or give any things of value away.

●If you buy or are given anything of value.

YOU ARE BLIND OR DISABLED:

●If your condition improves or your doctor says you can return to work.

●If you go to work.

●If you stop or refuse any vocational rehabilitation services.

UNMARRIED AND UNDER AGE 22:

●If the child starts or stops school.

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES OR YOU BECOME A CITIZEN OF THE UNITED STATES.

PAGE 8 OF 8

How to Edit Capi Form Soc 814 Online for Free

By using the online PDF tool by FormsPal, you can fill in or edit DAPD here. To have our editor on the cutting edge of practicality, we work to implement user-driven capabilities and improvements on a regular basis. We're at all times looking for suggestions - play a pivotal role in reshaping the way you work with PDF files. Getting underway is simple! All you need to do is follow these simple steps down below:

Step 1: Click on the "Get Form" button above on this webpage to get into our PDF editor.

Step 2: Using this handy PDF editor, you can accomplish more than merely complete forms. Try all of the functions and make your documents seem great with customized textual content added, or adjust the original input to perfection - all comes along with an ability to add any type of graphics and sign the file off.

This PDF doc will require specific details; to ensure consistency, you should bear in mind the next guidelines:

1. It's vital to complete the DAPD accurately, hence be careful while filling out the parts including all these blanks:

2. Just after filling in the last section, go on to the next part and enter the essential particulars in these blank fields - Date Problems Began, Describe Health Problems, You, Your Spouse, Are you married, MARITAL STATUS, YES, Go to a, Spouses Name First Middle Initial, DATE OF BIRTH, SOCIAL SECURITY NUMBER, Did your spouse ever use any other, d Other names and Social Security, YES, and SSI Referral Completed.

soc 814 conclusion process described (portion 2)

It is easy to make a mistake while filling in your You, consequently make sure you look again before you decide to finalize the form.

3. Completing Are you a United States citizen If, b Have you or your spouse or, US Military Service, Are you lawfully admitted for, YOU, YOUR SPOUSE, YES, YES, YES, YES, YES, YES, b Give the date of lawful, Did any person institution or, and MO DAY YR is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

4. This next section requires some additional information. Ensure you complete all the necessary fields - US Resident, Yes, Passport viewed and copy on file, Month aid begins, Through what date will INS allow, What is your Alien Registration, What was your Port of Entry, RESIDENCY, YOU, YOUR SPOUSE, Are you hiding or running from, or a parole or probation violation, YOU, YOUR SPOUSE, and YES - to proceed further in your process!

5. The very last notch to conclude this form is pivotal. Make sure you fill in the necessary fields, and this includes Check the applicable block to show, Room commercial establishment, Nursing Home, Jail, Shelter for Battered Women Other, a Do you need assistance in your, b Do you have adequate cooking and, available, YOU, YOUR SPOUSE, YES, YES, YES, YES, and IHSS Referral NMOHC, before using the pdf. If not, it might produce an unfinished and possibly unacceptable document!

The right way to fill in soc 814 portion 5

Step 3: Ensure that the information is accurate and then just click "Done" to conclude the task. Right after getting afree trial account at FormsPal, it will be possible to download DAPD or send it via email without delay. The PDF form will also be available through your personal cabinet with your every single edit. FormsPal ensures your information privacy by having a secure method that in no way saves or shares any sort of personal information used. Rest assured knowing your paperwork are kept safe any time you work with our tools!

Capi Form Soc 814 – Fill Out and Use This PDF

Capi Form Soc 814 PDF Details

Form Preview Example

How to Edit Capi Form Soc 814 Online for Free

Capi Form Soc 814 isn’t the one you’re looking for?

Related Documents