E. Did your housing or utility costs change when you moved? If YES, complete 1, 2 and 3 below:
You may be asked to provide proof of your new shelter costs.
1. Enter the amount of each housing cost you have.
2. If you have utility costs, check the box
for each utility cost you have.
3. Did anyone not part of your CalFresh household help you pay any of your housing or utility costs? If YES, complete 3a, b and c.
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CERTIFICATION
• I understand that failing to report information or intentional misrepresentation of facts can result in legal prosecution with penalties of a fine,
imprisonment or both. The penalties can result in disqualification from CalFresh, fine up to $250,000 and imprisonment up to 20 years. The
disqualification penalties are 12 months for the first violation, 24 months for the second violation, and permanent disqualification for the third
violation.
•
I understand that I have only 10 days to tell my worker about changes in my household (Questions 1 - 6 only).
•
I understand that the facts I have reported will be matched and verified by local, state and federal staff.
•
I understand that the household, any adult member (even if they move out), the sponsor of an alien household member, or the authorized representative of
residents in an eligible institution may be required to repay extra benefits the household should not have received, even if it’s the County’s fault.
•
I understand that I have the right to ask for a state hearing on any action by the County Welfare Department.
•
I declare that the facts contained in this report are true, correct and complete.
A. Do you have a new mailing address or phone number or do you plan to move? If YES, complete 5 C, 5 D and 5 E.
B. Did you move? If , complete 5 C, 5 D and 5 E.
C. Does someone else live at this address? If YES, give name(s) and relationship:
___________________________________
D. Enter you new address and/or phone number below and enter the date of the change here:
__________________________
5
ADDRESS AND SHELTER COST CHANGES
Optional - If any household member who works, is looking for work, or is going to school, had an increase in dependent care or child care costs since they last reported,
pease complete the section below.
What was the amount paid: $____________ Who paid:________________________________________________
List child/children:_____________________________________________________________________________________________________________________
Has any member of the CalFresh household paid legally obligated child support for children not living in the home or with the household?
Attach proof of the court order or administrative order showing the requirement to pay the child support and give the amount paid. If there has
been a change in the amount of the legally obligated support, attach proof of the change.
7 DEPENDENT CARE EXPENSE CHANGES
6
CHILD SUPPORT PAID BY HOUSEHOLD
Do you think the changes in questions 1 through 6 are temporary?
If YES, explain.
9
TEMPORARY CHANGES
Home Address (Number and Street) Mailing Address (If Different)(Number and Street)
City Zip code
WHO PAID CHILD SUPPORT PAID TO WHOM AMOUNT PAID DATE PAID
SIGNATURE (HOUSEHOLD MEMBER OR AUTHORIZED REPRESENTATIVE) DATE
DATESIGNATURE (WITNESS, IF YOU SIGNED WITH AN X)
Home Phone
Utility
Gas or Fuel Garbage or Trash
Water
Sewage
Other(specify)
Electricity
Telephone
Utility Installation
Utility
Rent or Mortgage: $
Property Taxes or Insurance: $
(If not in mortgage)
Message PhoneCity Zip code
CF 377.5 CR (11/13)
8
MEDICAL EXPENSES (FOR A HOUSEHOLD MEMBER WHO IS DISABLED OR AGE 60 OR OLDER)
Who Had the Expense? Type of Expense Amount Who Had the Expense?
Type of Expense
Amount
$
$
Optional - If any household member who is disabled or age 60 or over has new or increased medical expenses, complete the section below as this report may
increase your allotment. If the expenses are new or are increased by more than $25, attach proof.
a. Enter the total housing costs paid
by the CalFresh household: $____________
b. Enter the total utility costs paid
by the CalFresh household: $____________
c. Give the name of each person who paid any of the costs, and if they paid housing
and/or utility costs:
