Form Soc 860 – Fill Out and Use This PDF

(Supplemental Application for Cash Assistance Program for Immigrants)

COUNTY USE ONLY

(TO BE COMPLETED BY SPONSOR AND SPONSOR’S SPOUSE, IF APPLICABLE)

CASE NAME:

INSTRUCTIONS: PLEASE ANSWER THE FOLLOWING QUESTIONS FOR YOURSELF

CASE #:

AND YOUR SPOUSE (IF LIVING TOGETHER) AND RETURN IT TO THE CAPI

APPLICANT/RECIPIENT OR THE COUNTY REPRESENTATIVE.

WORKER #:

CAPI Applicant/Recipient Name and Address

1.

SPONSOR’S SOCIAL SECURITY NUMBER (VOLUNTARY)*

DATE OF BIRTH

NAME (FIRST, MIDDLE, LAST)

TELEPHONE NUMBER

(

)

HOME ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)

MAILING ADDRESS (IF DIFFERENT THAN HOME ADDRESS)

2.

SPOUSE’S SOCIAL SECURITY NUMBER (IF LIVING TOGETHER) (VOLUNTARY)*

DATE OF BIRTH

VERIFIED:

■ Affidavit of Support on

NAME (FIRST, MIDDLE, LAST)

HAS SPONSOR’S SPOUSE SIGNED AN

AFFIDAVIT OF SUPPORT?

File

■ YES

■

NO

■ USCIS Verification

3.

Do you or your spouse get assistance such as: California Work Opportunity

and Responsibility to Kids (CalWORKs), Food Stamps, or Supplemental

■ YES

■

NO

■ Other: ____________

Security Income (SSI)? If Yes, complete below:

CASE NAME

TYPE OF ASSISTANCE

MONTHLY AMOUNT

COUNTY

STATE

VERIFIED:

$

■ Letter on File

$

■ Verbal Communication

■ Other: ____________

4.

Do you or your spouse have other persons who are claimed or could be

■ YES

■ NO

claimed as dependents for federal income tax purposes?

■ IRS Form 1040

NAME OF PERSON(S)

RELATIONSHIP

DATE OF BIRTH

DOES PERSON LIVE WITH SPONSOR?

■ YES

■

NO

Reviewed

■ Other: ____________

■ YES

■ NO

■ YES

■ NO

■ YES

■ NO

SOC 860 (12/09)

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5. Are you or your spouse currently employed?

■ YES

■ NO

COUNTY USE ONLY

If Yes, complete section below. Attach paystubs or other proof of earnings.

Name

Name of Employer

Gross pay

How Often Paid

Commissions

VERIFIED:

(Before

(Weekly, monthly,

or Tips

Deductions)

etc.)

Enter Date Viewed

Wage

Tax

Other

Stubs

Returns

6. Are you or your spouse self-employed?

■ YES

■ NO

If Yes, list business expenses on a separate sheet of paper and attach proof

of income and expenses or provide latest tax return.

7. Do you or your spouse receive or expect to receive any other income such

■ YES

■ NO

Specify Verification and Date

as: Social Security benefits, Unemployment/Disability Insurance,

Reviewed:

Child/Spousal Support, Veterans Benefits, etc?

If Yes, complete section below and attach proof of the income.

Name

Type of Income

Amount

How Often Received

Verification on File:

■ Yes

■ No

9.

Do you or your spouse have any of the following resources?

Check each item. If Yes, explain below.

VERIFIED:

Resource

Sponsor

Spouse

Resource

Sponsor

Spouse

Checks or Money (At

■ YES ■ NO

■ YES ■ NO

Trust Funds

■ YES ■ NO

■ YES ■ NO

Enter Date Viewed

Home or Elsewhere)

Bank

Certificates

Other

Checking, Savings, Credit

■ YES ■ NO

■ YES ■ NO

Stock, Bonds,

Statements

■ YES ■ NO

■ YES ■ NO

Union Account

Certificates

Notes, Mortgages, Trust

■ YES ■ NO

■ YES ■ NO

Other (Specify below)

■ YES ■ NO

■ YES ■ NO

Deeds, Sales Contracts

Type of Resource

Owner

Current

Location

Account

Value

(Home, Bank Address, etc)

Number

$

$

$

10. Do you or your spouse own (or are you buying) any real property, such as:

■ YES

■ NO

a house, land, building, etc. If Yes, complete section below:

Date Records Viewed?

Type of

How Used?

Balance

Name of

Name

Address/Location

Value

Mortgage Co.

Property

(Home, Rental,

etc.)

Owed

1._____________________

2._____________________

$

$

$

$

11.

Do you or your spouse own or use or are you buying any motor vehicle, such

■ YES

■ NO

as: A car, truck, boat, trailer, van, camper, motorcycle, etc. If Yes, complete

section below.:

Name

Year, Make, Model

Balance Owed

Value

SOC 860 (12/09)

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