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.

QuestionAnswer
Form NameCapi Form Soc 814
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namescapi 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

a. First Name, Middle Initial, Last Name

 

 

DATE OF BIRTH

 

SEX

SOCIAL SECURITY NUMBER

 

LINKAGE

 

SSN

ID

 

 

 

 

 

 

■ 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:

 

d.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

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

 

b.

 

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

ID

 

 

 

 

 

 

 

■ Aged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Go to #4a.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ Blind

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

DATE OF BIRTH

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

■ Disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ __-__ __-__ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

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

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soc 814 writing process shown (stage 1)

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!

How to fill in soc 814 stage 3

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Filling in segment 4 of soc 814

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

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