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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS FOR IN-HOME SUPPORTIVE SERVICES
Note: Your eligibility for In-Home Supportive Services (IHSS), under Welfare and Institutions Code Section 12300, will be
determined by the information you provide on this form.
APPLICANT INFORMATION
NAME (FIRST, MIDDLE, LAST)
BIRTHDATE
HOME ADDRESS
CITY ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
HOME PHONE
( )
MESSAGE PHONE
( )
PLACE OF BIRTH
SOCIAL SECURITY NUMBER MEDI-CAL CARD NUMBER
ARE YOU:
AGE 65 OR OVER? DISABLED? BLIND?
MARITAL STATUS:
SINGLE
MARRIED
(Date / / )
SEPARATED
(Date / / )
WIDOWED
(Date / / )
DIVORCED
(Date / / )
COMPLETE THE FOLLOWING:
NAME OF SPOUSE OR PARENT(S)
(IF YOU ARE UNDER 18 YEARS OF AGE)
IS SPOUSE/PARENT(S):
AGE 65 OR OVER? DISABLED?
BLIND?
SPOUSE/PARENT(S) SOC. SEC. NO. SPOUSE/PARENT(S) ADDRESS
(IF DIFFERENT THAN APPLICANT'S)
DO YOU RESIDE IN CALIFORNIA WITH THE
INTENTION TO CONTINUE RESIDING HERE?
YES NO
YES NO
YES NO
YES NO
ARE YOU A CITIZEN OF THE UNITED STATES?
(IF “YES”, GO TO “ITEM 4”)
(A.) IF YOU ARE NOT A UNITED STATES CITIZEN, ARE YOU
LAWFULLY ADMITTED TO PERMANENT RESIDENCE OR
LEGALLY PERMITTED TO REMAIN IN THE U S.?
(B.) WHAT IS YOUR ALIEN REGISTRATION NUMBER?
(C.) WHAT IS NAME OF SPONSOR?
(D.) WHAT IS SPONSOR’S ADDRESS?
WHAT IS YOUR LIVING ARRANGEMENT?
LANDLORD’S NAME
AMOUNT OF RENT, BOARD AND/OR MORTGAGE PAID
$______________/MONTH
ADDRESS CITY
ZIP CODE
ARE THERE OTHERS LIVING IN THE HOUSEHOLD?
(IF “YES”, GIVE THE INFORMATION BELOW:)
NAME
RELATIONSHIP
AGE
SOC 310 (1/03)
FOR COUNTY USE ONLY
MY HOME IS A:
IN WHICH I:
HOUSE APARTMENT ROOM
ROOM &
BOARD
LIVE
COST FREE
OWN/
AM BUYING
RENT
TRAILER/
MOTOR HOME OTHER
RECEIVE
BOARD AND CARE
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Page 1 of 4 pages
POLICY NUMBER
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN REAL PROPERTY OTHER THAN YOUR HOME?
(If “YES”, GIVE THE INFORMATION BELOW: OR ON PAGE 4 PARAGRAPH 21.)
ADDRESS
CITY COUNTY
STATE ZIP CODE
PARCEL NUMBER
ASSESSED VALUE
$
TOTAL AMOUNT OWED ON MORTGAGE(S)
$
MONTHLY PAYMENT
$
ANNUAL TAXES
$
ANNUAL INSURANCE
$
ANNUAL ASSESSMENTS
$
HOW IS PROPERTY UTILIZED? IF USED AS RENTAL, INDICATE
AMOUNT OF RENT.
ARE TAXES INCLUDED IN THE
MONTHLY PAYMENT?
OTHER PROPERTY EXPENSES IS INSURANCE INCLUDED IN
THE MONTHLY PAYMENT?
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN MOTOR VEHICLES (CARS, TRUCKS,
MOTORCYCLES, BOATS, MOTORHOMES)?
(IF “YES”, GIVE THE INFORMATION BELOW:)
MAKE AND
MODEL
YEAR
ESTIMATED
VALUE
WORK
CHECK IF USED FOR
MEDICAL
TRANS.
MODIFIED
FOR DISABLED
PERSON?
WHAT IS THE VALUE OF YOUR LIQUID RESOURCES?
(IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER AGE 18, INCLUDE RESOURCES OF PARENT(S) RESPONSIBLE FOR
CHILD, INDICATE IF ANY RESOURCE IS EXCLUSIVELY FOR BURIAL EXPENSES FOR YOU OR YOUR IMMEDIATE FAMILY.)
LIQUID RESOURCES
() IF
NONE
ENTER VALUE UNDER OWNER
SELF SPOUSE/PARENTS
JOINTLY
() FOR
BURIAL
CASH ON HAND AND/OR
MONEY KEPT IN THE HOME
CHECKING ACCOUNT
SAVINGS ACCOUNT, CREDIT UNION
TRUST FUNDS
CHECKS OR CASH IN SAFETY DEPOSIT
BOX
STOCKS, BONDS, OR MUTUAL FUNDS
NOTES, MORTGAGES, DEEDS
IRA, CERTIFICATES OF DEPOSIT, MONEY
MARKET
OTHER
(SPECIFY):
DO YOU, YOUR SPOUSE OR PARENT(S) (IF APPLICANT IS UNDER 18) HAVE ANY PERSONAL GOODS
OR HOUSEHOLD EFFECTS WITH A COMBINED EQUITY VALUE OF MORE THAN $2,000?
(E. G., HOUSEHOLD FURNISHINGS, CLOTHING, AND JEWELRY.)
(IF ADDITIONAL SPACE IS NEEDED,
SPECIFY IN ITEM 21.)
(IF “YES”, GIVE INFORMATION BELOW:) (EXCLUDE REHABILITATION DEVICES AND EQUIPMENT.)
DESCRIPTION
CURRENT MARKET VALUE
AMOUNT OWED
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY LIFE INSURANCE?
(IF “YES”, GIVE THE INFORMATION BELOW:)
NAME OF OWNER NAME OF INSURED NAME AND ADDRESS OF INSURANCE COMPANY
TOTAL FACE
VALUE OF POLICY
CASH SURRENDER
VALUE
WHEN WAS THE
POLICY PURCHASED
IF THERE IS A LOAN
AGAINST THE POLICY
WHAT IS THE AMOUNT
Page 2 of 4 pages
FOR COUNTY USE ONLY
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
$
$
$
$
$
$
$
$$A.
$$B.
$$C.
$
$
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$
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$
$
$
$
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DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BURIAL FUNDS, INSURANCE,
TRUSTS, SPACES OR CONTRACTS?
(IF “YES”, GIVE THE INFORMATION BELOW:)
OWNER OF
EACH ITEM
NAME OF
EACH ITEM
TOTAL PURCHASE
VALUE OF EACH ITEM
HOW MUCH IS OWED
ON EACH ITEM
NAME AND ADDRESS OF
COMPANY/SOURCE
$
$
$
$
$
$
HAVE YOU, YOUR SPOUSE OR PARENT(S) (IF A MINOR IS APPLYING) SOLD, TRANSFERRED
OR GIVEN AWAY ANY PROPERTY, INCLUDING MONEY, IN THE LAST 36 MONTHS?
(IF “YES”, GIVE THE INFORMATION BELOW:)
DESCRIPTION
DATE OF
TRANSFER
ESTIMATED
VALUE
AMOUNT
RECEIVED
ARE YOU OR YOUR SPOUSE EMPLOYED OR SELF—EMPLOYED?
(IF “YES”, GIVE THE
INFORMATION BELOW:) (IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER I8 INCLUDE
EMPLOYMENT OF PARENT(S).)
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
OCCUPATION
GROSS SALARY PER PAY PERIOD
HOW OFTEN PAID?
$
$$$
IF SELF-EMPLOYED, ATTACH VERIFICATION OF ALL ORDINARY AND NECESSARY BUSINESS EXPENSES, PRINCIPAL
PAYMENTS OR ENCUMBRANCES AND PERSONAL INCOME TAX.
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BUSINESS EQUIPMENT
INVENTORY, OR MATERIAL?
(IF “YES”, GIVE THE INFORMATION BELOW:)
DESCRIPTION
PURPOSE
ESTIMATED
VALUE
AMOUNT OWED
IF YOU ARE BLIND OR DISABLED AND WORKING, DO YOU HAVE ANY WORK—RELATED
EXPENSES DUE TO BLINDNESS OR DISABILITY?
(IF “YES”, GIVE THE INFORMATION BELOW:)
COST OF TRANSPORTATION TO AND FROM
WORK
COST OF ITEMS OR SERVICES TO PREPARE
FOR WORK
COST OF ITEMS OR SERVICES
NEEDED FOR JOB PERFORMANCE
LIST INCOME RECEIVED EACH MONTH FROM SOURCES OTHER THAN EMPLOYMENT. IF APPLICANT IS A BLIND OR
DISABLED CHILD UNDER AGE 18, INCLUDE INCOME OF PARENT(S) RESPONSIBLE FOR CHILD.
TYPE OF INCOME
()
NONE
ENTER MONTHLY AMOUNT RECEIVED BY
:
SELF
SPOUSE/PARENT(S)
CLAIM NUMBER
A. SOCIAL SECURITY
B. CASH CONTRIBUTIONS
STATE DISABILITY/
C. UNEMPLOYMENT INSURANCE
D. VETERAN’S PENSION/COMPENSATION
V.A. AID AND ATTENDANCE
E. CARE/ HOUSEBOUND ALLOWANCE
F. GOVERNMENT PENSION
PRIVATE AND/OR MILITARY
G. RETIREMENT PENSION
H. ALIMONY, CHILD SUPPORT
I. RENTAL INCOME
J. INTEREST, DIVIDENDS, ROYALTIES
K. RAILROAD RETIREMENT PENSION
L. WORKER’S COMPENSATION
M. AFDC PAYMENTS
N. OTHER:
(SPECIFY)
Page 3 of 4 pages
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(RETIREMENT, SURVIVOR,
DISABILITY INSURANCE)
FOR COUNTY USE ONLY
YES NO
YES NO
YES NO
YES NO
YES NO
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16.
HAVE YOU, YOUR SPOUSE OR YOUR PARENT(S) APPLIED FOR OR DO YOU EXPECT TO
START RECEIVING INCOME FROM ANY OF THE SOURCES LISTED IN “ITEM 16”?
(IF “YES”, GIVE THE INFORMATION BELOW:)
TYPE OF INCOME
PLACE APPLIED DATE APPLIED DATE EXPECTED
(A.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE ANY NON-CASH GIFTS OR
CONTRIBUTIONS OF RENT, FOOD, CLOTHING OR OTHER ITEMS OF NEED?
(B.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE NON-CASH COMPENSATION IN
RETURN FOR WORK?
(IF “YES” TO “(A)” OR “(B)”, GIVE THE INFORMATION BELOW:)
ITEM CONTRIBUTED
FREQUENCY OF
RECEIPT
CASH EQUIVALENT
DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE HEALTH OR HOSPITALIZATION
INSURANCE (INCLUDING PAID BY AN EMPLOYER)?
(IF “YES”, GIVE THE INFORMATION BELOW:)
INSURANCE CARRIER (CHECK APPLICABLE(S))
PERSON(S) INSURED
MEDICARE
(CLAIM NO. )
CHAMPUS
VETERAN’S ADMINISTRATION COVERAGE
KAISER
ROSS—LOOS
BLUE SHIELD
BLUE CROSS
PREPAID HEALTH PLAN
HEALTH MAINTENANCE ORGANIZATION
(SPECIFY: )
OTHER CARRIER
(SPECIFY: )
ITEM NUMBER
ADDITIONAL INFORMATION (ATTACH ADDlTlONAL SHEETS IF NECESSARY)
BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS THAT APPLY TO YOU. READ THE FOLLOWING CAREFULLY BEFORE SIGNING:
I HEREBY STATE BY MY SIGNATURE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE.
I AGREE TO TELL THE COUNTY DEPARTMENT OF SOCIAL SERVICES WITHIN 10 DAYS IF THERE ARE ANY CHANGES IN MY INCOME, POSSESSIONS. OR EXPENSES, OR IN THE
NUMBER OF PERSONS IN MY HOUSEHOLD, OR IF ANY CHANGE OF ADDRESS. AND I AGREE TO MEET ALL OTHER RESPONSIBILITIES EXPLAINED IN THE “MEDI–CAL
RESPONSIBILITIES CHECKLIST” I HAVE RECEIVED.
I UNDERSTAND THAT I MAY BE ASKED TO PROVE MY STATEMENTS, BUT THAT THE COUNTY IS REQUIRED BY LAW TO KEEP THEM CONFIDENTIAL.
I UNDERSTAND THAT IF I AM DISSATISFIED WITH ANY ACTIONS TAKEN BY THE COUNTY DEPARTMENT OF SOCIAL SERVICES, I HAVE THE RIGHT TO A STATE HEARING.
I UNDERSTAND THAT I MUST DISPOSE OF ANY EXCESS RESOURCES WITHIN A SIX–MONTH PERIOD IN THE CASE OF REAL PROPERTY AND WITHIN THREE MONTHS IN THE
CASE OF PERSONAL PROPERTY AND REPAY ANY OVERPAYMENTS WITH THE PROCEEDS OF THE DISPOSED PROPERTY.
I UNDERSTAND THAT IF I AM ELIGIBLE FOR IHSS SERVICES, I WILL BE PROVIDED A MEDI–CAL CARD AT NO SHARE–OF–COST TO ME IF I PAY THE IHSS SHARE OF COST I AM
OBLIGATED TO PAY.
I UNDERSTAND THAT FEDERAL AND STATE LAW REQUIRE THE RECOVERY OF ALL MEDI-CAL BENEFITS RECEIVED AFTER AGE 55 FROM THE ESTATE OF A MEDI–CAL
BENEFICIARY IF THERE IS NO SURVIVING SPOUSE, MINOR CHILDREN, OR PERMANENTLY AND TOTALLY DISABLED CHILDREN.
SOC 310 VERIFICATION
ELIGIBLE INELIGIBLE
REASON (IF INELIGIBLE):
SOCIAL SERVICE WORKER:
DATE:
I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.
SIGNATURE OF APPLICANT DATE
SIGNATURE OF WITNESS
(REQUIRED IF APPLICANT
SIGNED BY MARK)
SIGNATURE OF PERSON ACTING FOR APPLICANT
(RELATIONSHIP: PARENT, GUARDIAN, CONSERVATOR)
DATE
SIGNATURE OF PERSON HELPING APPLICANT
COMPLETE FORM
DATE
DATE
Page 4 of 4 pages
FOR COUNTY USE ONLY
EXPECTED INCOME
How Verified:
a. _____________________________
b. _____________________________
c. _____________________________
IN-KIND INCOME
30-775.11
How Verified: ____________________
_______________________________
_______________________________
_______________________________
_______________________________
PREMIUM PAYMENTS
Amount Paid: $ __________________
How often: ______________________
How Verified: ____________________
_______________________________
_______________________________
_______________________________
_______________________________
YES NO
YES NO
YES NO
YES NO
17.
HAVE YOU, YOUR SPOUSE OR YOUR PARENTS HAD MEDICAL EXPENSES WITHIN THE LAST
3 MONTHS AND WANT MEDI-CAL FOR THOSE EXPENSES?
YES NO
18.
19.
20.
$
$
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