Fillable MID-YEAR STATUS REPORT (California)

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MID-YEAR STATUS REPORT (California)

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The MID-YEAR STATUS REPORT (California) form is 2 pages long and contains:

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  • 20 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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_________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MID-YEAR STATUS REPORT
For CalWORKs and CalFresh
RECIPIENT’S NAME:
CASE NUMBER (IF KNOWN):
SOCIAL SECURITY NUMBER (OPTIONAL)
Use this form to report mandatory or voluntary changes that have occurred since your last redetermination/recertification
(RD/RC).
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 receive CalWORKs, report the information marked CW. If you receive CalFresh, report the information marked
CF. The change of address and voluntary information sections are for all households/assistance units.
CW
D
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 $ _________.
CW
D
Someone in my household is running from the law to avoid a felony conviction; running from the law, to
avoid custody or confinement after a felony conviction; or has been found by a court to be in violation
of probation or parole.
Name of person_______________________________________
CW/CF
D
Someone moved into or out of my household. (Attach a separate sheet for additional persons.)
1. Did the person move
D
In or
D
Out? (check one)
2. Name (First, Middle, Last)_________________________________________________________
3. Date of Birth (mm/dd/yyyy)________________________________________________________
4. Relationship to you______________________________________________________________
5. Regularly purchase and prepare together?
D
Yes
D
No (check one)
CW/CF
D
I have moved, changed my phone number or have a new mailing address.
New home address _________________________________________
New mailing address (if different from your home address) ___________________________________
New phone number (______)_____________________
D
I receive free rent at this new address.
D
I receive free utilities at this new address.
My rent amount is $ _________ per month. My utilities are $_________ per month.
AR 3 (2/15) RECOMMENDED FORM
PAGE 1 OF 2
_______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
MANDATORY INFORMATION - continued
CF
D
I have had a change in income (check one):
D
Total monthly income has stopped.
D
Earned income changed by more than $100.
D
Unearned income changed by more than $50.
D
Source of income changed.
D
New income started.
CF
D
A change has occurred in the amount of legally obligated child support.
CF
D
Complete this section to report reduced work or training hours for Able-Bodied Adults Without
Dependents:
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)________________________________________
Relationship to you _______________________________________
Explain what happened____________________________________
Date of change __________________________________________
VOLUNTARY INFORMATION (All households/Assistance Units)
I would like to report the following information:
CERTIFICATION
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. 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 for the entire report month.
WHO MUST SIGN
BELOW:
For CalWORKs: you, your aided spouse, CA Domestic Partner or the other parent (of cash aided
children) if living in the home.
For CalFresh: the head of household, responsible household member or the household’s authorized
representative.
Signature or Mark Date Signed Home Phone Contact Phone
Signature of Spouse, Registered Domestic Partner,
or Other Parent of Cash Aided Children
Date Signed Signature of Witness to Mark, interpreter or
other person completing form
Date Signed
AR 3 (2/15) RECOMMENDED FORM
PAGE 2 OF 2
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MID-YEAR STATUS REPORT (California)

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Completed 30 December 2022

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