Form Qr 22 - Sponsor'S Statement Of Facts Income And Resources
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4STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSORED NONCITIZENS APPLYING FOR OR RECEIVING
CASH AID AND/OR FOOD STAMPS
Important Information For Noncitizens Sponsored
Important Information For Sponsors
By Individuals
The noncitizen you sponsor has applied for Cash Aid
and/or Food Stamps. If you completed an affidavit of
As a noncitizen who is sponsored by an individual(s),
support, State regulations require the county welfare
you must meet special conditions to receive Cash Aid
department to evaluate your income, resources, and
and/or Food Stamps.
property in deciding whether or not the noncitizen applicant
can get benefits. Sponsorship is normally for an indefinite
The Special Conditions Are:
period of time. This form must be completed and signed
by you under penalty of perjury. If you are living with your
•
Your sponsor’s income and resources will have to be
spouse or your spouse has signed an affidavit of support,
reviewed for you to receive benefits. Your sponsor
your spouse’s income, resources, and property are also
must provide information on the attached form. Both
counted.
you and your sponsor must sign this form.
•
If your application is approved, you and your sponsor
If the noncitizen’s application for Cash Aid is approved,
each quarter you will have to report your income,
will have to complete quarterly income and resource
resources, and property on the Sponsor’s Quarterly
reports for Cash Aid and Food Stamp benefits. If
Income and Resources Report (QR 72). The noncitizen will
your sponsor does not provide this information, your
provide you with the report form. Your report must be
benefits may be changed or stopped. Family
completed and returned to the noncitizen immediately to
members who are not sponsored and are otherwise
ensure the noncitizen’s continued eligibility. Each quarter,
eligible can get and continue to get their benefits.
resources and a portion of your income will be used to
•
You are the person responsible for getting all the
determine the noncitizen’s continued eligibility and
information requested to the county welfare
benefits.
department for both you and your sponsor.
If the noncitizen receives benefits to which he or she is not
entitled because you failed to accurately report information,
you and/or the noncitizen may have to repay these
benefits.
QR 22 COVERSHEET (12/06) REQUIRED FORM – NO SUBSTITUTES PERMITTED
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