Form Sar 3 - Mid-Period Status Report For Cash Aid And Calfresh
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MID-PERIOD STATUS REPORT
For Cash Aid and CalFresh
CASE NUMBER (IF KNOWN):
RECIPIENT’S NAME:
Use this form to report mandatory or voluntary changes that have occurred since you last reported.
If you are reporting income information, please provide proof, such as: pay stubs; copies of checks; letters from agencies; etc.
If you’re having problems getting the proof and need help, call the county.
If you are reporting changes in expenses, please provide proof, such as: receipts; canceled checks; paid invoices; etc. If
you’re having problems getting the proof and need help, call the county.
If you are reporting an address change, please provide proof of expenses such as: a copy of your new rental agreement or
lease; rent receipt for your new address; copies of utility deposits; etc.
MANDATORY INFORMATION
If you get Cash Aid, report the information marked CA. If you get CalFresh, report the information marked CF.
Sections marked CA/CF are for all households/assistance units.
CA/CF
My combined household income is more than the limit for my household size.
In the month of ________________ , the total combined income for my household is $ _________.
CA
Someone in my household is hiding or running from the law to avoid prosecution, being taken into
custody, or going to jail for a felony crime or attempted felony crime.
Name of person_______________________________________
CA
Someone in my household has been found by a court of law to be in violation of probation or parole.
Name of person_______________________________________
CA
I have moved, changed my phone number or have a new mailing address.
New home address _________________________________________
_________________________________________
New mailing address (if different from your home address) ___________________________________
New phone number (______)_____________________
I get free rent at this new address.
I get free utilities at this new address.
My rent amount is $ _________ per month.
My utilities are $_________ per month.
I share the rent; my share is $__________.
I have:
Heating
Cooling
I became homeless.
Water
Sewer
Garbage
Telephone
Other
See other side
SAR 3 (2/15) RECOMMENDED FORM
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