Form Ca Qr7 – Fill Out and Use This PDF

COUNTY OF LOS ANGELESDEPARTMENT OF PUBLIC SOCIAL SERVICES

GENERAL RELIEF QUARTERLY REPORT

TO KEEP YOUR BENEFITS COMING ON TIME, PLEASE SIGN THE FORM AFTER ____________1ST AND RETURN IT BY __________5TH. YOUR QR 7 IS

CASE NAME: CASE NUMBER:

(Bar Code)FILE/UNIT NUMBER: WORKER PHONE:

NEED HELP? CALL YOUR WORKER

9You must report all of the income received in the Report Month of ___________________.

9If you do not send in a complete QR 7 report, including but not limited to, answering all questions and attaching proof when the question says to attach proof, your benefits may be delayed, changed, or stopped. Attach a separate sheet of paper if needed. Facts you report may result in your benefits going up, down or stopped.

9The following changes are considered mandatory reporting responsibilities; therefore you must report these changes within 5 days of the occurrence to your eligibility worker and on your quarterly report:

9All other changes are considered voluntary reporting responsibilities. Although voluntary they must be reported on your General Relief quarterly report (QR7-LA).

Request to Stop Benefits (if you fill in this part, sign and date the back of this form. You can reapply at any time.) I ask that my: General Relief be stopped on the last day of: ____________ (MONTH/YEAR)

1.Did you or anyone get any income or money from any source this MONTH? … YES … NO If “Yes”, list below and ATTACH PROOF. Earnings: Babysitting, interest or dividends, rental income, salary, self-employment, sick pay, tips, vacation pay, etc.

Any Government Benefits: State Disability Indemnity (SDI), Social Security, Supplemental Security Income/State Supplementary Payment (SSI/SSP), other government disability or retirement, rental assistance, unemployment, veteran’s retirement, Worker’s Compensation, etc. Other Benefits: Spousal support, insurance or legal settlements, other private disability or retirement, railroad retirement, strike benefits, etc. Other: Cash, gifts, loans, scholarships, etc. Income In-Kind: Such as earned housing, free housing/utilities/clothing/food, etc.

1a. Number of hours worked or in training in this MONTH:

1b. If the income or money reported above will change in the next three months after the SUBMIT MONTH, please explain and

ATTACH PROOF.

REPORT WELFARE FRAUD - CALL HOTLINE (800) 349-9970

QR 7- LA (10/12) GENERAL RELIEF QUARTERLY REPORT

PART 2: What Has Happened SINCE Your Last Report?

1.Did anyone: Get, buy, sell, trade, or give away any property, land, home, cars, bank accounts, money, payments (such as; lottery or casino winnings, retroactive social security, tax refunds), or other property items since last report?

…YES … NO

If “YES”, list all items below and ATTACH PROOF.

3.Are you or has someone in your household:

A.Been convicted of a drug-related felony after 12/31/97 and an unaided member of a family unit receiving CalWORKs; or

B.Fleeing to avoid prosecution or custody/conviction of a felony; or

C.In violation of parole/probation

If “YES”, list below and ATTACH PROOF. Attach a separate sheet of paper if needed.

Family Change [Married, divorced, separated, registered as a California Domestic Partnership (DP), have a non-California DP, ended a DP, became pregnant, had a baby, or no longer pregnant?]

Disability (Became disabled or recovered from a disability or major illness?)

Work (Started or stopped working, refused a job or training, number of hours worked or in training went up or down, or went out on strike?)

Immigration (Citizenship or immigration status change, or got a new card, form, or letter from USCIS/INS?) Insurance (Started, stopped, or changed health, dental, or life insurance benefits, including MEDICARE?) Custody (Any change in the amount of time you care for/have custody of your children?)

In-Home Supportive Services (Started or stopped getting services?)

School Attendance (For Student - stopped or started attending school regularly?)

Other:

ADDRESS CHANGE Fill in this section ONLY if you have moved or have a new mailing address.

CERTIFICATION – FRAUD WARNING

I UNDERSTAND THAT: If on purpose I do not report all facts or give wrong facts about my income, property, or family status to get or keep getting aid or benefits, I can be legally prosecuted. I may also be charged with committing a felony if more than $950 in General Relief, is wrongly paid out as a result of such action. I have received a copy of the Instructions and Penalties for the General Relief Eligibility Status Report.

YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE MONTH THIS REPORT IS FOR OR IT WILL BE CONSIDERED INCOMPLETE.

I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this report are true and correct and complete.