Form Arc 1 - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (Arc) Funding Option Program Page 2

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
5. Does the child/youth get or expect to get any income, such as:
Verification provided
YES
NO
Earnings, Supplemental Security Income/State Supplementary
I DON’T KNOW
Payment (SSI/SSP), Social Security Benefits, Child Support,
Income:
Veterans Benefits, etc.
Earned
If “YES,” complete below:
Unearned
Exempt
AMOUNT (before
WHEN
HOW OFTEN
TYPE OF INCOME
deductions, if any)
FC 2
$
Will this income continue?
YES
NO
If “NO,” explain any known changes:
I DON’T KNOW
Verification provided
6. Does the child/youth own any property or have resources, such
YES
NO
Exempt
as: cash, land, vehicle, motorcycle, bank accounts, trust funds,
I DON’T KNOW
savings bonds, Native American per capita payments or trust
FC 2
funds, or other items?
If “YES,” complete below:
TYPE OF
ACCOUNT/POLICY
RESOURCE
NUMBER
$
Total: _____________________
$
_________ I have received and understand the Rights and Responsibilities (ARC 1A) document.
Initial here
CERTIFICATION
I understand that:
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility is fraud
and that I may be subject to penalties under state and federal law if I provide false or untrue information. Fraud can cause a criminal
case to be filed against me and/or I may be barred for a period of time (or life) from getting ARC benefits.
• I understand that Social Security Numbers or Immigration Status for household members applying for benefits may be shared with the
appropriate government agencies as required by federal law.
I declare under penalty of perjury under the laws of the State of California that the information contained on this Statement of
Facts is true, correct, and complete to the best of my knowledge.
SIGNATURE OF APPROVED RELATIVE CAREGIVER
DATE
COUNTY USE ONLY
:
NOTES
INELIGIBLE (Reason)
ELIGIBLE
Payment Authorization Date:
CalWORKs Eligible
ARC-only Eligible
Date
Signature of County Worker
Signature of Supervisor
Date
ARC 1 (11/16) REQUIRED FORM – NO SUBSTITUTE PERMITTED
PAGE 2 OF 2

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