STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

060 Rancho Park COUNTY OF LOS ANGELES

11110 W PICO BLVD
LOS ANGELES, CA 90064-1709
Date: 04/25/2024
Case Name: Gach Chuol
Case Number: L226DA7
Worker Name: Customer Service
Worker ID: 19DP606F0B
SAR 7 ELIGIBILITY STATUS REPORT Worker Phone Number: (866) 613-3777

GACH K CHUOL
330 DENEVE DR # J13B
LOS ANGELES, CA 90024

For Mailing Purposes Only

Please remove this page before returning the attached form.

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COUNTY OF LOS ANGELES
Date: 04/25/2024
Case Name: Gach Chuol
Case Number: L226DA7
Worker Name: Customer Service
Worker ID: 19DP606F0B
FIRST-CLASS MAIL PERMIT NO. 50762 LOS ANGELES CA
POSTAGE WILL BE PAID BY ADDRESSEE Worker Phone Number: (866) 613-3777

DPSS - CSU III - NORTHRIDGE

9451 CORBIN AVE STE 200
NORTHRIDGE, CA 91324-9935

NEED HELP? CALL YOUR WORKER REPORT MONTH: April YEAR: 2024

TO KEEP YOUR BENEFITS COMING ON TIME, PLEASE SIGN THE FORM AFTER May 1st AND RETURN IT BY May 5th

For CalWORKs your family size is .Your IRT is $ For CalFresh, your household size is 1 . Your IRT is $1580
Check the box if you would like to STOP getting any of the following: STOP my CalWORKs STOP my CalFresh STOP my Medi-Cal

1. Has anyone moved into or out of your home (including newborns) or did you move in with someone else since you last reported?
YES NO (if yes, complete the section below)
Regularly Purchase And Prepare
Date of Move (mm/dd/yy) Name (First, Middle, Last) Date of Birth (mm/dd/yy) Relationship To You
Food Together?
In Out / / / / YES NO

In Out / / / / YES NO

In Out / / / / YES NO

2. Have there been any changes to your address since you last reported? Yes No (if yes, complete the section below)
New Address: Date Moved:
Number, Street, City, Zip Code
Mailing Address (if different than above)

3. If you have moved since you last reported, please fill out the section below:
Your rent or mortgage per month now? If paid separately, your property taxes and home insurance per month now?
$ $
Do you have utility costs that are not included in your rent or mortgage payment? If so, check which ones:
Phone Trash Water Electric/Gas Other heating or cooling costs

4. CalWORKs only: Is anyone in your home:

A. Running from an outstanding warrant?
B. Found by a court to be in violation of probation or parole?
YES NO (if yes, complete the section below)

Name of person A or B from above In what state was the warrant issued, or did violation happen? Date of warrant or violation

5. Medical Costs: If anyone who gets CalFresh and is 60 years old or older, or disabled, had an increase in medical costs please complete the section below and attach
proof:

Who had the change? Amount of increase: $

6. Child Support: Did anyone who gets CalFresh have a change in the amount of child support they have to pay since they last reported? YES NO
If yes, complete the section below and attach proof.

What was the amount paid in the Report Month? $ Who paid support?
7. Dependent Care: If anyone who gets CalFresh and either works, is looking for work, or is going to school, had an increase in out-of-pocket dependent care costs since
they last reported, please complete the section below and attach proof:
What was the amount paid out-of-pocket in the Report Month? $
Who paid: List dependent(s):

INCOME 11.73-Gach K Chuol -EARNED INCOME INCOME

INCOME INCOME INCOME
INCOME INCOME INCOME
WELFARE FRAUD HOTLINE Newborn
(800)349-9970

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 8. Did anyone: Get, buy, sell, trade or give away any property, land, homes, cars, bank accounts, money, payments (such as lottery/casino
winnings,back benefits from social security), or other property items since last reported?
YES NO (if yes, complete the section below and attach proof. If you need more space, attach a separate piece of paper)

Who? Type of Property? When? Amount/Value? Bought Sold Gave Away Spent
Got as a Gift Traded Won Other
9. Did anyone get income from employment in the Report Month? YES NO (if yes, complete the section below and attach proof). The Report Month
is listed at the top of the first page. List each job for each person who works. If you need more space, attach a separate piece of paper. Examples include
babysitting, salary, self-employment, sick pays, tips, etc. If you lost your job, attach proof.
Job #1 Job #2 Job #3
Name of person who got income:
Source of income/Employer name: Self-employed, check here Self-employed, check here Self-employed, check here
Weekly Biweekly Other Weekly Biweekly Other Weekly Biweekly Other
How often paid: Monthly Twice Monthly
Monthly Twice Monthly Monthly Twice Monthly

Gross amount of income they got in the $ $ $

report month: DATE(S) RECEIVED: DATE(S) RECEIVED: DATE(S) RECEIVED:
Hours worked per month:
10. Will there be any changes to your income from employment in the next six months (including income listed in #9)? YES NO (If yes,
explain here and attach proof). Examples: Stopping or starting a job; increase or decrease of income; changes in hours; quitting a job or going on strike;
change in how often you are paid.

11. Did anyone get money from any other source in the Report Month? YES NO (If yes, complete the section below and attach proof). The Report Month is listed at
the top of the first page. Examples include: Social Security, Unemployment Compensation, Veteran’s Benefits, State Disability Insurance (SDI), Child/Spousal Support, Worker’s
Compensation, Loan/Gifts, Earned/Unearned Housing, Utilities, Food, etc. If you no longer get money from a source you previously reported, attach proof.
Name Source of income One time payment or monthly How much
$
$
$
12. Will there be any changes to money received from any other source in the next six months (including money listed in #11)? YES NO
(If yes, explain here and attach proof). Examples of changes: An increase or decrease in income or benefits, or if you will start or stop getting income or benefits.

13. CalWORKs only: Have any of the following happened to anyone in your home since you last reported? YES NO (if yes, check below and attach proof):
Family Change (Married, divorced, separated, entered into California Registered Domestic Partnership (RDP), have a non-California Domestic Partnership (DP),
(DP), ended DP or RDP, became pregnant, or is no longer pregnant?)
Job/Employment (Start, stop, quit a job, started a business or went on strike?)
Disability (Became disabled or recovered from a disability or major illness?)
Immigration (Citizenship or immigration status change, or got a new card, form, or letter from USCIS (INS)?)
Insurance (Started, stopped, or changed health, dental, or life insurance benefits, including MEDICARE?)
Custody (Any change in the amount of time you care for/have custody of your children?)
In-Home Support Services (Started or stopped getting services?)
School Attendance
• For Age 18 or older student – started or stopped school/college? (You may be able to claim costs for books, school transportation, etc.
Someone paid for all my housing, food, clothing or utility costs. (please explain)
Other

Please read carefully, sign and date.

By signing this form:
• I understand and certify, under penalty of perjury, that all my answers on this report are correct and complete to the best of my knowledge.

• I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000. I may have to pay back benefits if I was not
eligible to them. The first time I break the rules on purpose I will not be able to get CalFresh for one year; the second time two years; and after the third time I will not be
able to get CalFresh again.
• I understand and agree to give copies of all documents needed to complete my semi-annual report.
• I understand that in some instances, I may be asked to give consent to the County to make whatever contacts are necessary to determine eligibility.
CERTIFICATION - FRAUD WARNING
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. I may also be charged with committing a felony if more than $950 in Cash Aid, and/or CalFresh is wrongly paid out as a result of such an action. I have received a copy
of the Instructions and Penalties for the SAR 7 Eligibility Status Report for Cash Aid and CalFresh.
YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE REPORT MONTH OR IT WILL BE CONSIDERED INCOMPLETE.
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.
WHO MUST For Cash Aid: You and your aided spouse, registered domestic partner, or the other parent (of cash-aided children) if living in the home.
SIGN BELOW: For CalFresh: The head of household, a responsible household member, or the household's authorized representative.
SIGNATURE OR MARK DATE SIGNED HOME PHONE CONTACT/CELL PHONE CONTACT/CELL PHONE
→ ( ) - ( ) -
SIGNATURE OF SPOUSE, REGISTERED DOMESTIC PARTNER, OR DATE SIGNED SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER DATE SIGNED
OTHER PARENT OF CASH-AIDED CHILDREN PERSON COMPLETING FORM
→ →

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