General Relief Report Form – 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

CONSIDERED LATE IF NOT RECEIVED BY THE 11TH OF THE SUBMIT MONTH. SUBMIT MONTH

SUBMIT MONTH

CASE NAME: CASE NUMBER:

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

NEED HELP? CALL YOUR WORKER

MAIL BACK TO ADDRESS:

ADDRESSEE:

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

If 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.

The 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:

All 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)

PART 1: Please tell us what happened in ________________	___________
REPORT 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.

Who got the	From?	Gross amount	$	$	$	$	$
income?
		Date received
Who got the	From?	Gross amount	$	$	$	$	$
income?
		Date received

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.

COUNTY USE ONLY

EW Initials:

CHANGE ( )

NO CHANGE ( ) Date:

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.

Who owns, sold, traded, or gave	Type of Property		When?			Value	฀ Bought			฀ Sold	฀ Won
away?						$
							฀ Gift			฀ Traded	฀ Gave
							Received				Away
Checking Account ฀ Opened ฀ Closed Balance $				Savings Account ฀ Opened			฀ Closed		Balance $
2. Has anyone moved into or out of your home, or did you move in with someone else?										YES NO
Full name of person	Relationship to you				Moved in or out?					When?

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

YES NO	If “YES”, Name:	Where convicted?	Date of conviction:
4. Have any of the following or any other changes happened to anyone in your home?			฀ YES ฀ NO

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.

NEW Home Address (Number, Street Name, Avenue, Blvd., Etc.) Apt. No.							New Phone Number
City			State		Zip Code		(	)
Date Moved		NEW Mailing Address (if different from Home Address)
		City		State		Zip Code
Do you have housing costs at this new address?				Do you have to pay heating/cooling costs separate from your housing cost?
฀ YES ฀ NO	If yes, how much $			฀ YES ฀ NO	If yes, how much? $

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.

WHO MUST SIGN BELOW: You and your aided spouse or aided domestic partner if living in the home.

SIGNATURE OR MARK	DATE SIGNED	HOME PHONE	CONTACT/CELL PHONE
		( )	(	)
SIGNATURE OF AIDED SPOUSE OR AIDED	DATE SIGNED	SIGNATURE OF WITNESS TO MARK, INTERPRETER OR			DATE SIGNED
DOMESTIC PARTNER.		OTHER PERSON COMPLETING FORM