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HOW TO FILL OUT YOUR SAR 7 ELIGIBILITY STATUS REPORT For Cash Aid and CalFresh (formerly known as Food Stamp) Benefits Save this form to help you fill out your SAR7 (Eligibility Status Report).


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HOW TO FILL OUT YOUR SAR 7 ELIGIBILITY STATUS REPORTFor Cash Aid and CalFresh (formerly known as Food Stamp) BenefitsSave this form to help you fill out your SAR 7 (Eligibility Status Report). If you need help filling out your report, call the County. If you do not send in a complete report, your benefits may be delayed, changed, or stopped, or causean overpayment that you will have to pay back. You must answer all the questions, and attach proofwhen we ask for it. Questions 4 and 13 are CalWORKs only, households only receiving CalFresh arenot required to answer these questions. Attach a separate sheet of paper if needed. Facts you report may cause your benefits to go up, down, or be Often You Must Complete the SAR 7Once a year; (6 months after your application/annual renewal).The County will tell you when your SAR 7 is For People Who Are Living In Your HomeIf your family gets cash aid, report facts for: All children-natural, adopted, and stepchildren. All parents-natural, adoptive, and stepparent. Other aided relativesin the child s case. Yourselfand your spouse or registered domestic partner. Anyone who istemporarily absentfrom the your family gets CalFresh(with or without cash aid) youmust also report facts for: All children. All related adults. All other people in the household who regularly buy andprepare food with To Stop Benefits On the SAR 7, fill out the section to stop benefits onlyif youwant to stop any of your benefits. Check the benefits youwant stopped, and sign and date the SAR you only wantto stop some of your benefits and keep others, you must fillout the rest of the SAR 7. You can also stop your benefits by contacting the County. If you ask to have your cash aid stopped, your Medi-Cal mayalso be stopped or changed. You may not be eligible forMedi-Cal or you may have to pay a share of cost for TO FILL OUT EACH QUESTIONHousehold information (Question 1)List any changes in who lives with you, changes to your address(including changes in apartment number, and changes in housingcosts since you last reported). This includes: newborns; peoplewho are temporarily absent from the home; or anyone who died,entered or left a hospital or institution (including jail or prison), Change/Housing Costs (Questions 2 and 3)Give us the facts about any changes in your address or phonenumber since you last reported. If you are getting CalFresh, youmay be asked to give proof of new housing costs like rent andutilities. If your costs have increased because of the move, be sureto list the new amounts. This may increase your CalFresh and Parole/Probation Violations (CalWORKs only)(Question 4)This question applies to anyone already living with you who hadany of these happen since you last reported. It is ALSO foranyone who moved into your household who is running from thelaw or in violation of parole/probation. We need the person sname, the place, and the date the warrant was issued or theviolation you reported the information to the County before, you do notneed to report the same information. Expenses (CalFresh Information) (Questions 5, 6 and 7)These questions may change your CalFresh benefits. Thisinformation may lower the income we count and increase yourbenefits. For people age 60 and older or who are disabled, reportany changes to your out of pocket medical costs. For anyCalFresh household, report changes to your costs for child oradult dependent care needed for work or training. If you pay childsupport, report any changes in the amount paid. Attach proof tosee if you can get more benefits. SAR 7A (12/14) REQUIRED FORM - SUBSTITUTES PERMITTEDProperty (Question 8)List anyone who got, bought, sold, traded, spent or gave awayany property. Property includes: land, home, cars, bankaccounts, money payments (lottery or casino winnings, retroactivesocial security, tax refunds, etc). Include gifts and loans. Listwhose property, the type of property, when it changed, and thevalue of the property ( amount on the form). Check the box forwhat happened. Attach you have already reported and provided proof of new property,you do not have to report it again unless there has been Income (Question 9)List allincome from employment (work) earnings, tips, trainingallowances, benefits, or other earnings anyone got in the reportmonth. List the amount before taxes or deductions (the grossamount). Attach proof. Employment incomeincludes but is not limited topaychecks, cash income, vacation pay, bonuses, money fromself-employment, temporary job or training income, rentalincome, IHSS, etc. If self-employed, you can get a 40% deduction for expenseswithout proof. If your expenses are higher and you want toclaim actual expenses, list all business expenses on aseparate sheet of paper. Attach proof if using actualexpenses. Proof of job loss includes but is not limited to a letter fromthe employer, UIB award letter, or if no other verification isavailable, a signed written in Employment Income (Question 10)We need to know if income will continue or if there will bechanges. If your income will stay the same, we will use theamount you report as your income for the next 6 months. If youknow there will be changes in income, tell us why, how much andwhen. If you aren t sure, you can also report the change when ithappens. For example, if you were offered a job and know yourhourly wage and schedule, you must report this even if youhaven t started working or been paid yet. Also, if you are workingon-call or have a schedule that changes a lot, write thisinformation on your SAR 7 of employment income includes but is not limited to:check stubs, copies of checks or statements from the employeretc., or tax statements for self-employed. Other Income (Question 11)List allother income from any other source. Attach proof. Disability or Retirement incomeincludes SSI, SocialSecurity, Veteran s disability benefits, worker s compensationor any other disability/retirement payments. Unemployment benefits Other: lottery winnings; insurance or legal settlements; giftsor loans; rental assistance; free housing/utilities/clothing/food(or if someone paid all of these costs for you); or anythingelse. Proof of no longer receiving other moniesincludes but isnot limited to a letter from the benefit provider or if no otherverification is available, a signed written (1) who got the income, (2) where they got the money from,and (3) the amount they in Other Income (Question 12)Tell us if you think the income will continue or if you know it willchange. If you know it will change, tell us when it will change andhow OTHER SIDE FOR MORE INFORMATIONCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCALIFORNIA DEPARTMENT OF HEALTH CARE SERVICESINSTRUCTIONSSTATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCYPAGE 1 OF 2 If the County gets your report too late in the month todecrease your benefits based on what you reported, youmay be charged with an overpayment and have to pay itback. If your report is not complete when you turn it in, you will beasked to complete the questions you did not answer and/orturn in the proof that the report asked for. Your benefits maybe late. If you sign and date your report before the first day of thesubmit month, you will be asked to sign and date it again. If you are not sure how to report, what to report or what proofyou need to send in, ask the County. If your cash aid stops, you may still be eligible for CalFreshbenefits even if you are now employed. If your cash aid stops, you may still be eligible for no-cost orlow-cost health coverage under FRAUD: Welfare fraud is when you fail to report information, or reportthe wrong information, on purpose in order to try to get morebenefits. Fraud is a FOR CASH AIDWELFARE FRAUD:If you areconvicted of fraud or if you are disqualified for intentionally (onpurpose) not reporting your eligibility information correctly, youmay lose your share of the cash aid. How long you will lose itdepends on what the crime was and whether you hadcommitted fraud before. You may also have to pay a fine up to$10,000 and/or be sent to jail or prisonfor up to 3 years. Your cash aid can be stopped: For not reportingall facts or for giving wrong facts: 6 monthsfor the first time, 12 months for the second time, or foreverfor the third. For turning in more than one applicationto get aid for thesame family members in a different case in the same timeperiod: 2 years for the first conviction, 4 years for the second,andforeverfor the third. For convictionof felony welfare fraud penalties are: 2 yearsfor extra benefits under $2,000; 5 years for amounts of$2,000 through $4,999; and foreverfor amounts of $5,000or more. Forever:for giving the county false proof of residency inorder to get aid in two or more counties or states at the sametime; intentionally (on purpose) giving the county wrong factsfor an ineligible child or a child that does not exist; gettingmore than $10,000 in cash benefits through fraud; getting athird conviction for fraud in a court or an FOR CalFreshFRAUD: If you are convicted of fraud or if you are disqualified forintentionally (on purpose) not reporting your eligibilityinformation correctly, your CalFresh can be stopped for 12months for the first violation, 24 months for the second, andforeverfor the third. You may be fined up to $250,000 and/orsent to jail or prisonfor 20 years. Your CalFresh can be stopped if you are found guilty in anycourt of law or administrative hearing because: You traded or sold CalFresh benefits for firearms,ammunition, or explosives, your CalFresh benefits can bestopped foreverfor the first violation. You traded or sold CalFresh benefits for controlledsubstances. Your CalFresh benefits can be stopped for 24months for the first violation and foreverfor the second. You traded or sold CalFresh benefits that were worth $500 ormore. Your CalFresh benefits can be stopped forever. You gave the county false identity or residence information,to try to get CalFresh benefits in more than one case at thesame time. Your CalFresh benefits can be stopped for of other types of income includes but is not limited to:check stubs, copies of the checks, award letters from the agencyyou got the money from, Other Changes (CalWORKs only) (Question 13)List other things that could change your eligibility or the amount ofyour benefits. Examplesof changes you should report are listedon the SAR MUST SIGN THE SAR 7 For Cash Aid:You and your aided spouse, registereddomestic partner, or the other parent (of cash-aidedchildren), if they live in your home. For CalFresh:The head of household, authorizedrepresentative, or responsible household member. And for Both:Any other person who helps fill out the report,an interpreter, or the witness to your WE MEAN WHEN WE SAYRUNNING FROM THE LAW:A person is considered avoidingor running from the law if an arrest warrant has been issued andthe person knew or should have known from the facts that lawenforcement was looking for AID:CalWORKs (California Work Opportunity andResponsibility to Kids), Refugee Cash Assistance (RCA),Trafficking and Crime Victim Assistance Program (TCVAP), andEntrant Cash Assistance (ECA).CHILD SUPPORT PAYMENT:The payment you must make toa person for your child or stepchild. Include payments made bya stepparent living in your SAR 7:A SAR 7 is complete only when: All of the YES/NO questions are answered, and All of the information is filled in, and All of the proof is attached when the form asks for it, and All of the required signatures are on the form, and The form is signed and dated after the last day of the AMOUNT:The amount of your paycheck or othercheck (unemployment benefit, retirement, etc.), beforedeductions are taken out for taxes, social security, VIOLATION OF PROBATION OR PAROLE:A court hasfound you to be in violation of the terms of your probation orparole. The original crime for which probation or parole wasordered could be for a felony or MONTH: The month shown at the top of the SAR all income you got and any changes that happened inthis MONTH: The month you sign and date the report andturn it in. The submit month is shown at the top of the SAR 7,under the report SECTION You must sign the SAR 7 under penalty of perjury. Thismeans that you swear (promise) that the facts you give usare true, correct, and complete. Perjury is a crime it means you swore (promised) to tell thetruth and then you were : The report is due by the 5th of the submit month. Try to get itin on time to avoid problems with your benefits. If your report is late (after the 11th of the submit month), notcomplete or not turned in, your benefits may be late,changed, or 7A (12/14) REQUIRED FORM - SUBSTITUTES PERMITTEDPAGE 2 OF 2SEE OTHER SIDE FOR MORE INFORMATION

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