Fillable Income In-Kind/Housing Verification (Supplement To The MC 210 Statement Of Facts) (Department of Health Care Services)

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Income In-Kind/Housing Verification (Supplement To The MC 210 Statement Of Facts) (Department of Health Care Services)

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WE NEED THE FOLLOWING INFORMATION TO DETERMINE THE
VALUE OF THE HOUSING/RENT, UTILITIES, FOOD, OR CLOTHING
THAT YOU ARE RECEIVING FREE OR IN EXCHANGE FOR WORK.
PART I. (IN-KIND INCOME VERIFICATION)
A. Applicant Authorization Section (Sign this section if you want the county to verify IN-KIND INCOME.)
Name(s)
Address (number, street) City ZIP code
I hereby authorize _____________________________ County to contact _______________________________________
concerning any of the information requested below.
Applicant signature Date
➤
B. Provider Statement Section (Statement of person giving/sharing housing, utilities, food, clothing, etc.)
1. The person(s) named above receives from me/my family:
❒ Housing/Rent ❒ Utilities ❒ Food ❒ Clothing ❒ Cash
" This is ❒ free ❒ in exchange for___________________________________________________________________________
" I/We have been providing these items since________________________________________________________
" I/We expect to continue to provide these items until__________________________________________________
2. I/We share household expenses with the person(s) named above. ❒ Yes ❒ No
(If no, go to number 3.)
Our shared arrangement is ________________________________________________________________________
3. List the TOTAL cost of household items at the above address.
Housing Rent Utilities Food Clothing Cash
$$$$$ $
" The number of people in the household at the above address is________________________________________
4. My relationship to the person(s) named above is _______________________________________________________
I CERTIFY THAT THE INFORMATION IN THIS SECTION IS TRUE AND CORRECT.
Provider signature Date
➤
Address (number, street) City State ZIP code Telephone number
( )
PART II. HOUSING VERIFICATION
SIGN BELOW ONLY IF YOU, THE APPLICANT, WANT TO PROVIDE INFORMATION ABOUT FREE HOUSING OR RENT PAID
TO A RELATIVE AS EVIDENCE OF RESIDENCY. BEFORE YOU SIGN, YOU MUST FILL IN THE HOUSING INFORMATION
REQUESTED ABOVE.
I understand that the information I provide as evidence of residency may be verified by county or state employees processing
my application. I agree to cooperate with any such employee in the verification of this information.
I hereby authorize any county or state employee responsible for administering the Medi-Cal program to
contact __________________________________________________ concerning any of the information provided above.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
INFORMATION CONTAINED IN THIS STATEMENT IS TRUE, CORRECT, AND COMPLETE.
Applicant signature Date
➤
INCOME IN-KIND/HOUSING VERIFICATION
(SUPPLEMENT TO THE MC 210 STATEMENT OF FACTS)
COUNTY USE ONLY
Case name
Case number
Eligibility worker number Date
State of California—Health and Human Services Agency Department of Health Care Services
MC 210 S-I (09/08)
NECESITAMOS LA SIGUIENTE INFORMACIÓN PARA DETERMINAR
EL VALOR DE LA VIVIENDA/ALQUILER, SERVICIOS PÚBLICOS Y
MUNICIPALES, ALIMENTOS O ROPA QUE USTED RECIBE GRATIS O
A CAMBIO DE TRABAJO.
PARTE I. VERIFICACÍON DE LOS INGRESOS NO EN EFECTIVO
A. Sección de Autorización del Cliente (Firme esta sección si usted desea que el condado verifique los INGRESOS
NO EN EFECTIVO)
Nombre(s)
Dirección (número, calle) Cuidad Codigo postal
Por medio de la presente autorizo al condado de ___________________________________ a que se comunique con
___________________________________________ con relación a cualquier información que se solicita enseguida.
Firma del solicitante Fecha
➤
B. Sección para la Declaración del Proveedor (Declaración de la persona que da/comparte la vivienda, servicios
públicos y municipales, alimentos, ropa, etc.)
1. La(s) persona(s) mencionada(s) arriba recibe(n) de mí/de mi familia:
❒ Vivienda/Alquiler ❒ Servicios públicos y municipales ❒ Alimentos ❒ Ropa ❒ Dinero en efectivo
" Esto es ❒ gratuito ❒ a cambio de______________________________________________________________________
" He/Hemos proporcionado estos artículos desde ____________________________________________________
" Espero/Esperamos continuar proporcionando estos artículos hasta _____________________________________
2. Comparto/Compartimos los gastos del hogar con la(s) persona(s) mencionada(s) arriba. ❒ Sí ❒ No
(Si no es así, pase al número 3.)
Nuestro arreglo de compartir es: ____________________________________________________________________
3. El costo TOTAL de los gastos del hogar en la dirección anterior es:
Vivienda Alquiler Servicios públicos y Alimentos Ropa Dinero en efectivo
municipales
$$$$$ $
" El número de personas en el hogar en la dirección anterior es: ________________________________________
4. Mi relación/parentesco con la(s) persona(s) mencionada(s) arriba es:_______________________________________
CERTIFICO QUE LA INFORMACIÓN QUE CONTIENE ESTA SECCIÓN ES VERDADERA Y CORRECTA.
Firma del proveedor Fecha
➤
Dirección (número, calle) Ciudad Estado Codigo postal Número de teléfono
( )
PARTE II. VERIFICACION DE VIVIENDA
FIRME ABAJO SOLAMENTE SI USTED, EL SOLICITANTE, DESEA PROPORCIONAR INFORMACÍON ACERCA DE
VIVIENDA GRATUITA O ALQUILER (RENTA) QUE SE LE PAGA A ALGUN PARIENTE COMO PRUEBA DE RESIDENCIA.
ANTES DE FIRMAR, USTED TIENE QUE COMPLETAR LA INFORMACIÓN SOBRE VIVIENDA QUE SE LE PIDE ARRIBA.
Entiendo que la información que yo proporcione como prueba de residencia, pudiera ser verificada por empleados del condado
o del estado para tramitar mi solicitud. Estoy de acuerdo en cooperar con tal empleado en la verificación de esta información.
Por medio de la presente, autorizo a los empleados del condado o del estado, que sean responsables de administrar el
programa de Medi-Cal, a ponerse en contacto con ____________________________ con relación a cualquier información que
he proporcionado arriba.
DECLARO BAJO PENA DE PERJURIO, EN CONFORMIDAD CON LAS LEYES DEL ESTADO DE CALIFORNIA, QUE LA
INFORMACIÓN QUE CONTIENE ESTA DECLARACIÓN ES VERDADERA, CORRECTA, Y COMPLETA.
Firma del solicitante Fecha
➤
State of California--Health and Human Services Agency Department of Health Care Services
tment of Health Services
PARA USO DEL CONDADO
Case name
Case number
Eligibility worker number Date
INGRESOS—NO EN EFECTIVO/VERIFICACIÓN DE VIVIENDA
(SUPLEMENTO A LA DECLARACIÓN DE DATOS MC 210)
MC 210 S-I (09/08)
Case name
Case number
Eligibility worker number Date
COUNTY USE ONLY
INGRESOS - NO EN EFECTIVO/VERIFICACION DE VIVIENDA
(SUPLEMENTO A LA DECLARACION DE DATOS MC 210)
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Income In-KindHousing Verification (Supplement To The MC 210 Statement Of Facts) (Department of Health Care Services)

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Completed 30 July 2020

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