Form Soc 310 PDF Details

In any field of study, it is important to be able to communicate effectively. The ability to write well is a critical skill for any student, regardless of their chosen discipline. English Grammar is one of the most important aspects of communication, and it is essential that students have a strong understanding of the rules which govern our language. In this blog post, we will discuss some common English grammar mistakes which students often make. We will also provide tips on how to avoid these mistakes. So, if you are looking to improve your written communication skills, read on!

QuestionAnswer
Form NameForm Soc 310
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesBIRTHDATE, SHAREOFCOST, CHAMPUS, california department of social services forms

Form Preview Example

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATEMENT OF FACTS FOR IN-HOME SUPPORTIVE SERVICES

NOTE: Your eligibility for In-Home Supportive Services (IHSS), under Welfare and Institutions Code Section 12300, will be determined by the information you provide on this form.

1.APPLICANT INFORMATION

NAME (FIRST, MIDDLE, LAST)

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (IF DIFFERENT)

 

 

 

 

 

HOME PHONE

 

 

MESSAGE PHONE

 

 

 

 

 

 

 

 

 

(

)

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE OF BIRTH

 

 

SOCIAL SECURITY NUMBER

MEDI-CAL CARD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ AGE 65 OR OVER?

 

■ DISABLED?

 

 

 

■ BLIND?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARITAL STATUS:

■ MARRIED

 

■ SEPARATED

■ WIDOWED

 

 

■ DIVORCED

■ SINGLE

 

 

 

(Date /

/ )

 

(Date / / )

 

(Date /

/ )

 

 

(Date / / )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SPOUSE OR PARENT(S) (IF YOU ARE UNDER 18 YEARS OF AGE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS SPOUSE/PARENT(S):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ AGE 65 OR OVER?

■ DISABLED?

 

 

 

■ BLIND?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE/PARENT(S) SOC. SEC. NO.

SPOUSE/PARENT(S) ADDRESS (IF DIFFERENT THAN APPLICANT'S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

DO YOU RESIDE IN CALIFORNIA WITH THE

 

 

 

 

 

 

■ YES

■ NO

 

INTENTION TO CONTINUE RESIDING HERE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

ARE YOU A CITIZEN OF THE UNITED STATES?

 

 

 

■ YES

■ NO

 

(IF “YES”, GO TO “ITEM 4”)

 

 

 

 

 

 

 

 

 

(A.) IF YOU ARE NOT A UNITED STATES CITIZEN, ARE YOU

 

 

 

 

 

 

 

 

 

 

LAWFULLY ADMITTED TO PERMANENT RESIDENCE OR

 

 

 

■ YES

■ NO

 

LEGALLY PERMITTED TO REMAIN IN THE U S.?

 

 

 

(B.) WHAT IS YOUR ALIEN REGISTRATION NUMBER? (C.) WHAT IS NAME OF SPONSOR?

(D.) WHAT IS SPONSOR’S ADDRESS?

4.WHAT IS YOUR LIVING ARRANGEMENT?

MY HOME IS A: ■ HOUSE ■ APARTMENT

■

 

ROOM &

TRAILER/

 

■ OTHER

ROOM ■ BOARD

■ MOTOR HOME

IN WHICH I:

OWN/

 

 

LIVE

RECEIVE

 

 

 

■ AM BUYING

■ RENT

 

■ COST FREE

■ BOARD AND CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LANDLORD’S NAME

 

 

 

 

AMOUNT OF RENT, BOARD AND/OR MORTGAGE PAID

 

 

 

 

 

$______________/MONTH

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

CITY

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. ARE THERE OTHERS LIVING IN THE HOUSEHOLD?

 

 

 

■ YES

■ NO

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

RELATIONSHIP

 

 

AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COUNTY USE ONLY

SOC 310 (1/03)

Page 1 of 4 pages

6.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN REAL PROPERTY OTHER THAN YOUR HOME?

■ YES

■ NO

FOR COUNTY USE ONLY

(If “YES”, GIVE THE INFORMATION BELOW:

OR ON PAGE 4 PARAGRAPH 21.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

ZIP CODE

 

PARCEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSED VALUE

 

 

 

TOTAL AMOUNT OWED ON MORTGAGE(S)

 

 

MONTHLY PAYMENT

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNUAL TAXES

 

ANNUAL INSURANCE

 

 

ANNUAL ASSESSMENTS

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOW IS PROPERTY UTILIZED?

 

IF USED AS RENTAL, INDICATE

 

 

ARE TAXES INCLUDED IN THE

■ YES

■ NO

 

 

 

 

 

AMOUNT OF RENT.

 

 

MONTHLY PAYMENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PROPERTY EXPENSES

 

 

 

 

 

 

 

 

IS INSURANCE INCLUDED IN

■ YES

■ NO

 

 

 

 

 

 

 

 

 

 

 

 

THE MONTHLY PAYMENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN MOTOR VEHICLES (CARS, TRUCKS,

 

 

 

■ YES

■ NO

 

MOTORCYCLES, BOATS, MOTORHOMES)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAKE AND

 

 

 

ESTIMATED

 

CHECK IF USED FOR

MODIFIED

 

 

MODEL

 

YEAR

 

VALUE

 

WORK

 

MEDICAL

FOR DISABLED

 

 

 

 

 

 

 

 

TRANS.

PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

WHAT IS THE VALUE OF YOUR LIQUID RESOURCES?

(IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER AGE 18, INCLUDE RESOURCES OF PARENT(S) RESPONSIBLE FOR CHILD, INDICATE IF ANY RESOURCE IS EXCLUSIVELY FOR BURIAL EXPENSES FOR YOU OR YOUR IMMEDIATE FAMILY.)

LIQUID RESOURCES

(✓) IF

 

 

ENTER VALUE UNDER OWNER

(✓) FOR

 

NONE

 

SELF

SPOUSE/PARENTS

JOINTLY

BURIAL

 

 

 

 

 

 

 

 

CASH ON HAND AND/OR

 

 

$

 

$

$

 

MONEY KEPT IN THE HOME

 

 

 

 

 

 

 

 

 

 

 

CHECKING ACCOUNT

 

 

$

 

$

$

 

 

 

 

 

 

 

 

 

SAVINGS ACCOUNT, CREDIT UNION

 

 

$

 

$

$

 

TRUST FUNDS

 

 

 

 

 

 

 

 

 

 

 

CHECKS OR CASH IN SAFETY DEPOSIT

 

 

$

 

$

$

 

BOX

 

 

 

 

 

 

 

 

 

 

 

STOCKS, BONDS, OR MUTUAL FUNDS

 

 

$

 

$

$

 

NOTES, MORTGAGES, DEEDS

 

 

 

 

 

 

 

 

 

 

 

IRA, CERTIFICATES OF DEPOSIT, MONEY

 

 

$

 

$

$

 

MARKET

 

 

 

 

 

 

 

 

 

 

 

OTHER (SPECIFY):

 

 

$

 

$

$

 

 

 

 

 

 

 

 

 

DO YOU, YOUR SPOUSE OR PARENT(S) (IF APPLICANT IS UNDER 18) HAVE ANY PERSONAL GOODS

9.OR HOUSEHOLD EFFECTS WITH A COMBINED EQUITY VALUE OF MORE THAN $2,000?

 

(E. G., HOUSEHOLD FURNISHINGS, CLOTHING, AND JEWELRY.)

(IF ADDITIONAL SPACE IS NEEDED,

■ YES

■ NO

 

SPECIFY IN ITEM 21.)

 

 

 

 

 

 

(IF “YES”, GIVE INFORMATION BELOW:) (EXCLUDE REHABILITATION DEVICES AND EQUIPMENT.)

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

 

 

 

CURRENT MARKET VALUE

 

AMOUNT OWED

 

 

 

 

 

 

 

 

 

A.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

B.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

C.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY LIFE INSURANCE?

■ YES

■ NO

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF OWNER

NAME OF INSURED

 

NAME AND ADDRESS OF INSURANCE COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER

TOTAL FACE

VALUE OF POLICY

CASH SURRENDER

VALUE

WHEN WAS THE

POLICY PURCHASED

IF THERE IS A LOAN AGAINST THE POLICY WHAT IS THE AMOUNT

Page 2 of 4 pages

11. DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BURIAL FUNDS, INSURANCE,

■ YES ■

 

FOR COUNTY USE ONLY

TRUSTS, SPACES OR CONTRACTS? (IF “YES”, GIVE THE INFORMATION BELOW:)

NO

 

 

 

 

 

 

 

OWNER OF

NAME OF

TOTAL PURCHASE

HOW MUCH IS OWED

NAME AND ADDRESS OF

 

 

EACH ITEM

EACH ITEM

VALUE OF EACH ITEM

ON EACH ITEM

COMPANY/SOURCE

 

 

$

$

12.HAVE YOU, YOUR SPOUSE OR PARENT(S) (IF A MINOR IS APPLYING) SOLD, TRANSFERRED

 

OR GIVEN AWAY ANY PROPERTY, INCLUDING MONEY, IN THE LAST 36 MONTHS?

 

 

■ YES

■ NO

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

DATE OF

 

ESTIMATED

AMOUNT

 

TRANSFER

 

VALUE

 

RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

13.

ARE YOU OR YOUR SPOUSE EMPLOYED OR SELF—EMPLOYED? (IF “YES”, GIVE THE

 

■ YES

■ NO

INFORMATION BELOW:) (IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER I8 INCLUDE

 

 

 

 

EMPLOYMENT OF PARENT(S).)

 

 

 

 

 

 

NAME OF EMPLOYER

ADDRESS OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCUPATION

GROSS SALARY PER PAY PERIOD

HOW OFTEN PAID?

 

$

IF SELF-EMPLOYED, ATTACH VERIFICATION OF ALL ORDINARY AND NECESSARY BUSINESS EXPENSES, PRINCIPAL

PAYMENTS OR ENCUMBRANCES AND PERSONAL INCOME TAX.

14.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BUSINESS EQUIPMENT

 

 

INVENTORY, OR MATERIAL?

 

 

 

■ YES

■ NO

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

 

PURPOSE

ESTIMATED

AMOUNT OWED

 

 

 

VALUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

IF YOU ARE BLIND OR DISABLED AND WORKING, DO YOU HAVE ANY WORK—RELATED

 

 

EXPENSES DUE TO BLINDNESS OR DISABILITY?

 

■ YES

■ NO

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

COST OF TRANSPORTATION TO AND FROM

COST OF ITEMS OR SERVICES TO PREPARE

COST OF ITEMS OR SERVICES

 

 

WORK

 

FOR WORK

NEEDED FOR JOB PERFORMANCE

 

$

 

$

 

$

 

 

16.LIST INCOME RECEIVED EACH MONTH FROM SOURCES OTHER THAN EMPLOYMENT. IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER AGE 18, INCLUDE INCOME OF PARENT(S) RESPONSIBLE FOR CHILD.

 

TYPE OF INCOME

(✓)

ENTER MONTHLY AMOUNT RECEIVED BY:

CLAIM NUMBER

 

 

NONE

SELF

SPOUSE/PARENT(S)

 

 

 

 

 

 

 

 

 

 

 

 

A.

SOCIAL SECURITY

(RETIREMENT, SURVIVOR,

 

$

$

 

 

DISABILITY INSURANCE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

CASH CONTRIBUTIONS

 

$

$

 

 

 

 

 

 

 

 

 

 

 

STATE DISABILITY/

 

 

$

$

 

 

C.

UNEMPLOYMENT INSURANCE

 

 

 

 

 

 

 

 

 

 

D.

VETERAN’S PENSION/COMPENSATION

 

$

$

 

 

 

 

 

 

 

 

 

 

V.A. AID AND ATTENDANCE

 

$

$

 

 

E.

CARE/ HOUSEBOUND ALLOWANCE

 

 

 

 

 

 

 

 

 

 

F.

GOVERNMENT PENSION

 

$

$

 

 

 

 

 

 

 

 

 

 

PRIVATE AND/OR MILITARY

 

$

$

 

 

G.

RETIREMENT PENSION

 

 

 

 

 

 

 

 

 

 

H.

ALIMONY, CHILD SUPPORT

 

$

$

 

 

 

 

 

 

 

 

 

 

I.

RENTAL INCOME

 

 

$

$

 

 

 

 

 

 

 

 

 

J.

INTEREST, DIVIDENDS, ROYALTIES

 

$

$

 

 

 

 

 

 

 

 

 

K.

RAILROAD RETIREMENT PENSION

 

$

$

 

 

 

 

 

 

 

 

 

L.

WORKER’S COMPENSATION

 

$

$

 

 

 

 

 

 

 

 

 

 

M.

AFDC PAYMENTS

 

 

$

$

 

 

 

 

 

 

 

 

 

 

N.

OTHER: (SPECIFY)

 

 

$

$

 

 

 

 

 

 

 

 

 

 

Page 3 of 4 pages

17.

HAVE YOU, YOUR SPOUSE OR YOUR PARENT(S) APPLIED FOR OR DO YOU EXPECT TO

 

 

FOR COUNTY USE ONLY

 

START RECEIVING INCOME FROM ANY OF THE SOURCES LISTED IN “ITEM 16”?

■ YES

■ NO

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

EXPECTED INCOME

 

 

 

 

 

 

 

TYPE OF INCOME

 

PLACE APPLIED

 

DATE APPLIED

 

DATE EXPECTED

How Verified:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. _____________________________

 

 

 

 

 

 

 

 

 

 

b. _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. _____________________________

18.

HAVE YOU, YOUR SPOUSE OR YOUR PARENTS HAD MEDICAL EXPENSES WITHIN THE LAST

■ YES

■ NO

 

 

 

 

3 MONTHS AND WANT MEDI-CAL FOR THOSE EXPENSES?

 

 

 

IN-KIND INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

(A.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE ANY NON-CASH GIFTS OR

■ YES

■ NO

30-775.11

 

 

 

 

 

 

CONTRIBUTIONS OF RENT, FOOD, CLOTHING OR OTHER ITEMS OF NEED?

How Verified: ____________________

 

 

 

 

 

 

 

 

 

 

 

(B.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE NON-CASH COMPENSATION IN

■ YES

■ NO

_______________________________

 

RETURN FOR WORK?

 

 

 

 

 

 

(IF “YES” TO “(A)” OR “(B)”, GIVE THE INFORMATION BELOW:)

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

ITEM CONTRIBUTED

 

FREQUENCY OF

 

CASH EQUIVALENT

 

 

 

 

 

 

 

 

 

 

RECEIPT

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

PREMIUM PAYMENTS

 

 

 

 

 

 

 

 

 

 

 

20.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE HEALTH OR HOSPITALIZATION

■ YES

■ NO

Amount Paid: $ __________________

INSURANCE (INCLUDING PAID BY AN EMPLOYER)?

 

 

 

 

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

How often: ______________________

 

 

 

 

 

 

 

 

 

 

 

INSURANCE CARRIER (CHECK APPLICABLE(S))

 

PERSON(S) INSURED

 

How Verified: ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ MEDICARE (CLAIM NO.

 

 

)

 

 

 

 

_______________________________

■ CHAMPUS

 

 

 

 

 

 

 

_______________________________

■ VETERAN’S ADMINISTRATION COVERAGE

 

 

 

 

 

 

 

 

 

 

_______________________________

■ KAISER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ ROSS—LOOS

 

 

 

 

 

 

 

_______________________________

■ BLUE SHIELD

 

 

 

 

 

 

 

 

 

 

■ BLUE CROSS

 

 

 

 

 

 

 

 

 

 

■ PREPAID HEALTH PLAN

 

 

 

 

 

 

 

 

 

 

■ HEALTH MAINTENANCE ORGANIZATION (SPECIFY:

)

 

 

 

 

 

 

 

■ OTHER CARRIER (SPECIFY:

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

ITEM NUMBER

 

ADDITIONAL INFORMATION (ATTACH ADDLTLONAL SHEETS IF NECESSARY)

 

SOC 310 VERIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ ELIGIBLE

■ INELIGIBLE

 

 

 

 

 

 

 

 

 

 

REASON (IF INELIGIBLE):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SERVICE WORKER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS THAT APPLY TO YOU. READ THE FOLLOWING CAREFULLY BEFORE SIGNING:

I HEREBY STATE BY MY SIGNATURE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE.

I AGREE TO TELL THE COUNTY DEPARTMENT OF SOCIAL SERVICES WITHIN 10 DAYS IF THERE ARE ANY CHANGES IN MY INCOME, POSSESSIONS. OR EXPENSES, OR IN THE NUMBER OF PERSONS IN MY HOUSEHOLD, OR IF ANY CHANGE OF ADDRESS. AND I AGREE TO MEET ALL OTHER RESPONSIBILITIES EXPLAINED IN THE “MEDI–CAL RESPONSIBILITIES CHECKLIST” I HAVE RECEIVED.

I UNDERSTAND THAT I MAY BE ASKED TO PROVE MY STATEMENTS, BUT THAT THE COUNTY IS REQUIRED BY LAW TO KEEP THEM CONFIDENTIAL.

I UNDERSTAND THAT IF I AM DISSATISFIED WITH ANY ACTIONS TAKEN BY THE COUNTY DEPARTMENT OF SOCIAL SERVICES, I HAVE THE RIGHT TO A STATE HEARING.

I UNDERSTAND THAT I MUST DISPOSE OF ANY EXCESS RESOURCES WITHIN A SIX–MONTH PERIOD IN THE CASE OF REAL PROPERTY AND WITHIN THREE MONTHS IN THE CASE OF PERSONAL PROPERTY AND REPAY ANY OVERPAYMENTS WITH THE PROCEEDS OF THE DISPOSED PROPERTY.

I UNDERSTAND THAT IF I AM ELIGIBLE FOR IHSS SERVICES, I WILL BE PROVIDED A MEDI–CAL CARD AT NO SHARE–OF–COST TO ME IF I PAY THE IHSS SHARE OF COST I AM OBLIGATED TO PAY.

I UNDERSTAND THAT FEDERAL AND STATE LAW REQUIRE THE RECOVERY OF ALL MEDI-CAL BENEFITS RECEIVED AFTER AGE 55 FROM THE ESTATE OF A MEDI–CAL BENEFICIARY IF THERE IS NO SURVIVING SPOUSE, MINOR CHILDREN, OR PERMANENTLY AND TOTALLY DISABLED CHILDREN.

I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.

SIGNATURE OF APPLICANT

DATE

SIGNATURE OF WITNESS (REQUIRED IF APPLICANT

DATE

 

 

SIGNED BY MARK)

 

 

 

 

 

SIGNATURE OF PERSON ACTING FOR APPLICANT

DATE

SIGNATURE OF PERSON HELPING APPLICANT

DATE

(RELATIONSHIP: PARENT, GUARDIAN, CONSERVATOR)

 

COMPLETE FORM

 

 

 

 

 

 

 

 

 

Page 4 of 4 pages

How to Edit Form Soc 310 Online for Free

If you wish to fill out CALIFORNIA, you don't need to download and install any programs - simply give a try to our online PDF editor. Our expert team is ceaselessly endeavoring to enhance the editor and insure that it is much better for people with its extensive features. Bring your experience one stage further with constantly developing and interesting possibilities available today! It merely requires just a few easy steps:

Step 1: First, open the pdf tool by pressing the "Get Form Button" above on this site.

Step 2: With this handy PDF editing tool, you can actually accomplish more than just fill out blank fields. Express yourself and make your docs look professional with customized text added in, or optimize the original input to perfection - all comes along with the capability to insert stunning pictures and sign the PDF off.

It is easy to fill out the form with our practical tutorial! Here is what you want to do:

1. The CALIFORNIA usually requires certain information to be entered. Ensure the subsequent blanks are finalized:

Part no. 1 for completing california department of social services forms

2. After finishing this step, head on to the subsequent step and complete all required particulars in these blank fields - A IF YOU ARE NOT A UNITED STATES, B WHAT IS YOUR ALIEN REGISTRATION, C WHAT IS NAME OF SPONSOR, D WHAT IS SPONSORS ADDRESS, YES, WHAT IS YOUR LIVING ARRANGEMENT, MY HOME IS A, HOUSE, APARTMENT, ROOM, ROOM BOARD, TRAILER, MOTOR HOME, OTHER, and IN WHICH I.

Part # 2 of filling out california department of social services forms

3. This next stage will be straightforward - complete all of the empty fields in SOC, and Page of pages to conclude this segment.

california department of social services forms completion process explained (stage 3)

Those who use this PDF often make mistakes while completing Page of pages in this section. Be certain to review everything you enter right here.

4. Filling in DO YOU YOUR SPOUSE OR YOUR PARENTS, YES, FOR COUNTY USE ONLY, ADDRESS, STATE, ASSESSED VALUE, ANNUAL TAXES, CITY, COUNTY, ZIP CODE, PARCEL NUMBER, TOTAL AMOUNT OWED ON MORTGAGES, MONTHLY PAYMENT, ANNUAL INSURANCE, and ANNUAL ASSESSMENTS is paramount in this form section - be certain to take the time and take a close look at each and every blank!

Completing segment 4 in california department of social services forms

5. The last stage to complete this form is pivotal. You'll want to fill in the required blank fields, particularly LIQUID RESOURCES, IF NONE, ENTER VALUE UNDER OWNER, SELF, SPOUSEPARENTS, JOINTLY, FOR BURIAL, CASH ON HAND ANDOR MONEY KEPT IN, CHECKING ACCOUNT, SAVINGS ACCOUNT CREDIT UNION TRUST, OTHER SPECIFY, DO YOU YOUR SPOUSE OR PARENTS IF, YES, DESCRIPTION, and CURRENT MARKET VALUE, prior to submitting. Neglecting to do this might produce a flawed and potentially unacceptable paper!

The best ways to fill out california department of social services forms portion 5

Step 3: Go through what you have typed into the blanks and then click on the "Done" button. Join FormsPal today and instantly gain access to CALIFORNIA, all set for download. Every single modification made is handily saved , which enables you to customize the form later if required. Here at FormsPal, we do everything we can to guarantee that all your information is stored private.

Form Soc 310 isn’t the one you’re looking for?

Related Documents