Form Ar 3 Mid-Year Status Report For Calworks And Calfresh Page 2
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1
2MANDATORY INFORMATION - continued
CF
I have had a change in income (check one):
Total monthly income has stopped.
Earned income changed by more than $100.
Unearned income changed by more than $50.
Source of income changed.
New income started.
CF
A change has occurred in the amount of legally obligated child support.
CF
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
For CalWORKs: you, your aided spouse, CA Domestic Partner or the other parent (of cash aided
BELOW:
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,
Date Signed
Signature of Witness to Mark, interpreter or
Date Signed
other person completing form
or Other Parent of Cash Aided Children
PAGE 2 OF 2
AR 3 (2/15) RECOMMENDED FORM
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