Form QR72 "Sponsor's Quarterly Income and Resources Report" - California

What Is Form QR72?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2006;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form QR72 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form QR72 "Sponsor's Quarterly Income and Resources Report" - California

1309 times
Rate (4.7 / 5) 79 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSOR’S QUARTERLY INCOME AND RESOURCES REPORT
THIS REPORT IS FOR THE MONTH OF
GIVE THIS TO YOUR SPONSOR
COMPLETE, SIGN, DATE AND RETURN THIS FORM AFTER:
CASE NAME
CASE NUMBER
SPONSOR’S INSTRUCTIONS
You and your spouse (if living together or if spouse has signed an affidavit of support) must complete and sign this report and return
it immediately to the noncitizen you sponsor.
The noncitizen must complete, sign and date the form, and return it to the county by the 5th of the month. If a complete report,
including verification, is not received by the 11th of the month, the noncitizen’s Cash Aid may be delayed, lowered, or stopped.
Call the county if you need help completing this form.
Noncitizen’s Name and Address
WORKER:
PHONE:
Sponsor’s Name (First, Middle, Last)
1
Answer the following questions for your spouse if she/he is living with you OR has signed an affidavit of support.
Sponsor’s Spouse’s Name (If Living Together) ( First, Middle, Last) Has sponsor’s spouse signed an
YES
NO
2
affidavit of support?
Do you and/or your spouse receive Cash Aid, such as California Work Opportunity and Responsibility to
YES
NO
3
Kids (CalWORKs) or Supplemental Security Income (SSI)?
If YES, complete below.
STATE
CASE NAME
DATE OF BIRTH
TYPE OF CASH AID
COUNTY
During the report month did you and/or your spouse receive income, money or benefits, such as: earnings,
YES
NO
4
training payments, earned income tax credit, strike benefits, social security, railroad retirement,
unemployment or disability insurance, interest, worker’s compensation, SSI/SSP, child/spousal support,
loans, grants, tax refund, cash gifts, free housing/utilities, etc.?
If YES, list who received income, employer’s name or other source of income, gross amount before
deductions, and actual date received. Attach paystubs or other proof of earnings for the report month.
Attach proof of any other income only when it starts and when it changes.
If self-employed, list business expenses on a separate sheet of paper and attach proof of income and
expenses.
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
If both you and your spouse (who is living with you) receive Cash Aid, skip to Question 10 and complete the Certification Section.
Since your last quarterly report, did you or your spouse have any changes in personal and/or real property,
YES
NO
5
such as: Receive, buy, sell or give away a motor vehicle, camper, boat, land or house, etc.?
If YES, explain the type of change, date of change and the amount, if applicable.
Did you or your spouse have a checking, savings or credit union account at the end of the report month?
YES
NO
6
If YES, complete below.
Whose Account?
Balance On Last Day of
Whose Account?
Balance On Last Day of
Credit Union
Credit Union
Report Month
Report Month
Checking
Checking
$
Savings
$
Savings
COUNTY USE ONLY
WORKER INITIALS
DATE
QR 72 (12/06) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SPONSOR’S QUARTERLY INCOME AND RESOURCES REPORT
THIS REPORT IS FOR THE MONTH OF
GIVE THIS TO YOUR SPONSOR
COMPLETE, SIGN, DATE AND RETURN THIS FORM AFTER:
CASE NAME
CASE NUMBER
SPONSOR’S INSTRUCTIONS
You and your spouse (if living together or if spouse has signed an affidavit of support) must complete and sign this report and return
it immediately to the noncitizen you sponsor.
The noncitizen must complete, sign and date the form, and return it to the county by the 5th of the month. If a complete report,
including verification, is not received by the 11th of the month, the noncitizen’s Cash Aid may be delayed, lowered, or stopped.
Call the county if you need help completing this form.
Noncitizen’s Name and Address
WORKER:
PHONE:
Sponsor’s Name (First, Middle, Last)
1
Answer the following questions for your spouse if she/he is living with you OR has signed an affidavit of support.
Sponsor’s Spouse’s Name (If Living Together) ( First, Middle, Last) Has sponsor’s spouse signed an
YES
NO
2
affidavit of support?
Do you and/or your spouse receive Cash Aid, such as California Work Opportunity and Responsibility to
YES
NO
3
Kids (CalWORKs) or Supplemental Security Income (SSI)?
If YES, complete below.
STATE
CASE NAME
DATE OF BIRTH
TYPE OF CASH AID
COUNTY
During the report month did you and/or your spouse receive income, money or benefits, such as: earnings,
YES
NO
4
training payments, earned income tax credit, strike benefits, social security, railroad retirement,
unemployment or disability insurance, interest, worker’s compensation, SSI/SSP, child/spousal support,
loans, grants, tax refund, cash gifts, free housing/utilities, etc.?
If YES, list who received income, employer’s name or other source of income, gross amount before
deductions, and actual date received. Attach paystubs or other proof of earnings for the report month.
Attach proof of any other income only when it starts and when it changes.
If self-employed, list business expenses on a separate sheet of paper and attach proof of income and
expenses.
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
NAME
SOURCE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
$
$
$
$
$
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
DATE RECEIVED
If both you and your spouse (who is living with you) receive Cash Aid, skip to Question 10 and complete the Certification Section.
Since your last quarterly report, did you or your spouse have any changes in personal and/or real property,
YES
NO
5
such as: Receive, buy, sell or give away a motor vehicle, camper, boat, land or house, etc.?
If YES, explain the type of change, date of change and the amount, if applicable.
Did you or your spouse have a checking, savings or credit union account at the end of the report month?
YES
NO
6
If YES, complete below.
Whose Account?
Balance On Last Day of
Whose Account?
Balance On Last Day of
Credit Union
Credit Union
Report Month
Report Month
Checking
Checking
$
Savings
$
Savings
COUNTY USE ONLY
WORKER INITIALS
DATE
QR 72 (12/06) REQUIRED FORM - SUBSTITUTE PERMITTED
PAGE 1 OF 2
Since your last quarterly report, was there a change in the number of persons who are claimed as depen-
YES
NO
7
dents for federal income tax purposes by you or your spouse? If YES, complete below.
DOES PERSON LIVE
DATE OF
NAME OF PERSON(S)
EXPLAIN WHAT CHANGED
WITH SPONSOR?
CHANGE
YES
NO
YES
NO
Since your last quarterly report, was there any change in payments made to persons who are claimed as
YES
NO
8
federal tax dependents who are not living with you or your spouse? If YES, explain what changed, list the
name of the person(s), amount paid and who paid:
During the report month, did you or your spouse pay any court-ordered support?
YES
NO
9
If YES, enter the amount paid and attach receipts: $
Do you or your spouse have any other information to report such as: a new address, a change in the
YES
NO
10
number of noncitizens that you sponsor and who will receive Cash Aid, recent or anticipated changes in
income, etc.?
If YES, explain the change and if it is expected to be temporary or permanent, and give the date of change.
CERTIFICATION SECTION
I understand that the term for Sponsorship is normally an indefinite period of time.
I understand that failure to report information or misrepresentation of facts for Cash Aid can result in legal prosecution with penalties
of a fine, imprisonment or both.
I understand that I may be required to repay any benefits which are overpaid because of incorrectly or incompletely reported
information.
SPONSOR’S CERTIFICATION
I declare under penalty of perjury under the laws of the State of California that the information contained in this report is true and
correct and is complete.
SIGNATURE OF SPONSOR
DATE
SIGNATURE OF SPONSOR’S SPOUSE (IF LIVING TOGETHER OR SIGNED AN AFFIDAVIT OF SUPPORT)
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
NONCITIZEN’S CERTIFICATION
I have reviewed this signed and completed report from my sponsor(s). I declare under penalty of perjury under the laws of the State
of California that, to the best of my knowledge, the information contained in this report is true and correct and is complete.
NONCITIZEN’S OR DECLARANT’S SIGNATURE OR MARK
DATE
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON COMPLETING FORM
DATE
COUNTY USE ONLY
Evaluation of Sponsor/Sponsor’s Spouse
CalWORKs
Food Stamps Sponsor/Sponsor’s Spouse
Real/Personal Property Resources
Sponsor/Sponsor’s Spouse Income Computation
Income Computation
A.
Earned Income
$ ____________
A.
ITEMS
VALUE
______________
$_______________
A.
Earned Income
$ __________
B.
Less 20%
- ____________
______________
$_______________
B.
Unearned Income
+ __________
C.
Unearned Income
+ ____________
______________
$_______________
D.
Gross Income Deduction
______________
$_______________
C.
Subtotal
= __________
for sponsor’s household
______________
$_______________
D.
Total number of sponsored
size
- ____________
noncitizens applying for/receiving
B.
Total
$ _______________
E.
Subtotal
= ____________
CalWORKs
__________
CW
FS
C.
Less: Food Stamp
F.
Total number of sponsored
NA
$1500
Deduction ($1500)
- _____________
E.
Divide C by D
= __________
noncitizens applying
D.
Subtotal
= _______________
for/receiving Food
F.
Number of sponsored noncitizens
E.
Total number of sponsored
in this AU
__________
Stamps
____________
noncitizens applying
G.
Total (Divide E by F)
= ____________
for/receiving CW/FS
_______________
G.
Total (Multiply E by F)
= __________
F.
Total (Divide D by E) = _______________
Amount in G to be deemed income for each
Amount in F to be included in each noncitizen’s
Amount in G to be deemed income for entire AU.
sponsored noncitizen.
property limits.
PAGE 2 OF 2
QR 72 (12/06) REQUIRED FORM - SUBSTITUTE PERMITTED
Page of 2