Form Cw 40 - Calworks Application For Reduced Income Supplemental Payment
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY USE ONLY
CalWORKS - REDUCED INCOME SUPPLEMENTAL PAYMENT
DATE POSTMARKED
SUPPLEMENTAL MONTH
REQUEST
YOU MAY GET EXTRA MONEY IF THE COUNTY IS COUNTING INCOME
CASE NUMBER
WORKER NAME/NUMBER
.
AGAINST YOUR CASH AID AND THAT INCOME HAS DROPPED OR STOPPED
A. ACTUAL GRANT AMOUNT
•
You must use this form to ask for the extra money.
(RISP Month)
$
•
You can only get extra money if your income, other than cash aid, dropped or
B. RISP MONTH ESTIMATED NET INCOME
stopped. You cannot use this form to get extra money for other reasons such as
1.
Total Disability-Based Unearned
$ ______________
birth of a child, clothing needs for children returning to school, or if you need to
Income (Income of AU and Non-AU Members)
move.
2.
$225 Disregard
- ______________
You must apply in the month that you need the extra money, not before or after.
•
3.
Subtotal Nonexempt Disability Based
You must complete and return a separate form during each month that the
•
Income (B1 minus B2)
county is counting income that has dropped or stopped.
(Enter positive amounts in B9)
(Enter negative amounts in B5)
= ______________
The county must determine your eligibility for extra money within 7 working days
after the date this completed form is received. If you don't need the form this month,
4.
Gross Earned Income
keep it for later.
(AU and Non-AU)
$ ______________
5.
Remainder of $225 Income Disregard - ______________
(Enter amount from line B3 if negative)
Questions? Ask your worker.
6.
Subtotal Earned Income
= ______________
(B4 minus B5)
Worker Name:
Phone: (
)
1.
Complete the following:
7.
50% Earned Income Disregard
- ______________
CASE NAME
YOUR SOCIAL SECURITY NUMBER
(B6 divided by 2)
8.
Subtotal (B6 minus B7)
= ______________
2.
Explain about the income that dropped or stopped. Complete below:
(Net Nonexempt Earned Income)
What Income Changed?
When?
Why Did It Change?
9.
Nonexempt Unearned Disability
Based Income
+ ______________
(Enter amount from line B3 if positive)
10. Other Countable Income of Family
3.
Attach proof of the change in income (Job Termination Notice, Social Security
____________________________
+ ______________
Notices, Disability/Unemployment Insurance Notices, Statements, etc.). If you
have no proof, list the employer or agency that can be contacted:
____________________________
+ ______________
EMPLOYER/AGENCY
PHONE
11. Net Nonexempt Income of Family
(
)
(Sum total of B8, B9 and B10)
$ ______________
ADDRESS
C. RISP MONTH AVAILABLE INCOME
1.
Actual Grant Amount (Enter from A)
$ ______________
4.
List money you expect to get this month of_____________________.
(CURRENT MONTH)
(Do not list your grant amount.)
2.
O/P adjustment (if used in actual
grant computation)
+ ______________
3.
Special Need (if used in actual
INCOME
SOURCE OF INCOME
grant computation)
- ______________
Gross Earnings
$
4.
Child/Spousal Support Disregard
+ ______________
Other Income
$
5.
Net Nonexempt Income
(Enter from B11)
+ ______________
6.
Penalties
CERTIFICATION
(Such as 25% Non-Co-op, school attendance, and immunization)
•
I understand that the statements I have made on this form are subject to investigation
______________________________
+ ______________
and verification including contacting the above named person, employer or agency.
______________________________
+ ______________
•
I further declare under penalty of perjury under the laws of the United States of
America and the State of California that the statements I have given on this form are
7.
Total Available Income
$ ______________
true and correct to the best of my knowledge.
D. RISP PAYMENT
•
I authorize the county to obtain any verification of income and circumstances
1. 80% of AU MAP
$ ____________
necessary to process this request. This authorization is valid for 30 days from the
date signed.
2. Total Available Income
(Enter from C7)
- ____________
SIGNATURE
DATE SIGNED
3. RISP Payment
$ ____________
SIGNATURE OF SPOUSE OR OTHER ADULT RECIPIENT
DATE SIGNED
PHONE
MESSAGE PHONE
APPROVED
DENIED
(
)
(
)
WORKER SIGNATURE
DATE
On this form, disclosure of your Social Security Number (SSN) is voluntary. The SSN will
be used to identify you and your records. If we cannot identify you, you may not get any
extra money.
CW 40 (ENG/SP) (3/00) APPLICATION FOR REDUCED INCOME SUPPLEMENTAL PAYMENT - REQUIRED FORM - SUBSTITUTE PERMITTED
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