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COUNTY OF

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SAR 3 (02/15) RECOMMENDED FORM
COUNTY OF
Date:
Case Name:
Case Number:
Worker Name:
Worker ID:
Worker Phone Number:
Customer ID:
Use this form to report mandatory or voluntary changes that have occurred since you last reported.
If you are reporting income information, please provide proof, such as: pay stubs; copies of checks; letters from agencies; etc.
If you’re having problems getting the proof and need help, call the county.
If you are reporting changes in expenses, please provide proof, such as: receipts; canceled checks; paid invoices; etc.
If you’re having problems getting the proof and need help, call the county.
If you are reporting an address change, please provide proof of expenses such as: a copy of your new rental agreement or
lease; rent receipt for your new address; copies of utility deposits; etc.
MANDATORY INFORMATION
If you get Cash Aid, report the information marked CA. If you get CalFresh, report the information marked CF.
Sections marked CA/CF are for all households/assistance units.
CA/CF
My combined household income is more than the limit for my household size.
In the month of
, the total combined income for my household is $
CA
Someone in my household is hiding or running from the law to avoid a prosecution, being taken into
custody or going to jail for a felony crime or attempted felony crime.
Name of person
CA
Someone in my household has been found by a court of law to be in violation of probation or parole.
Name of person
New mailing address (if different from your home address)
CA
I have moved, changed my phone number or have a new mailing address.
New home address:
New phone number
( )
I get free rent at this new address. .
My rent amount is $
per month.
I share the rent; my share is $
.
I became homeless.
I get free utilities at this new address.
My utilities are $
per month.
I have:
Heating Cooling
Water Sewer
Garbage Telephone
Other
SEE OTHER SIDE
RECIPIENT'S NAME: CASE NUMBER(IF KNOWN):
MID-PERIOD STATUS REPORT
For Cash Aid and CalFresh
SAR 3 (02/15) RECOMMENDED FORM
MANDATORY INFORMATION - continued
Fill out this section to report reduced work or training hours for Able-Bodied Adults without Dependents (ABAWDs).
(ABAWDs are adults between 19 and 50 who are not caring for minor children.)
CF
The number of hours worked or in training dropped below 20 hours a week or 80 hours a month to
hours per week or
hours per month.
Name of person(s):
Ralationship to you:
Explain what happened:
Date of change:
VOLUNTARY INFORMATION (All households/ Assistance Units)
I would like to report the following information:
CERTIFICATION
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 charged with a crime. And, I may be charged with committing a felony
if more than $950 in cash aid and/or CalFresh is wrongly paid out.
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:
For Cash Aid: You, your aided spouse, Registered Domestic Partner or the other parent (of cash aided children) if
living in the home.
For CalFresh: The head of household, household member or the household's authorized representative.
Signature or Mark Date Sign Home Phone Contact Phone
Signature of Spouse, Registered Domestic Partner
or other Parent of Cash Aided Children
Date Sign Signature of Witness to Mark,
interpreter or other person
completing form
Date Sign
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COUNTY OF

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Completed 12 October 2021

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