Form CW71 "Statement of Cash Aid Mother and Unrelated Adult Male (Uam)" - California

What Is Form CW71?

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 March 1, 2000;
  • 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 CW71 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form CW71 "Statement of Cash Aid Mother and Unrelated Adult Male (Uam)" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF CASH AID MOTHER
AND UNRELATED ADULT MALE (UAM)
You must give the county facts about the financial arrangements when an Unrelated Adult Male (not related to you or your children)
lives in a household that gets cash aid. These rules do not apply to roomers or borders.
The unrelated adult male who lives with you in your home must help pay each month for living expenses. The amount of money he
pays must be at least as much as it would cost him to live by himself. The state has rules for deciding how much this should be.
CASH AID MOTHER’S STATEMENT
An unrelated adult male lives with us.
I give the following facts about an unrelated adult male who lives with me and the arrangements we have entered into.
1
Name of Unrelated Adult Male
(First
M.I.
Last)
COUNTY USE ONLY
Case Name
2
We have lived together since:
Month
Day
Year
Case Number
3
Does he get aid, such as CalWORKs, General Assistance,
Unrelated Adult Male’s gross amount of monthly
Worker Name
Food Stamps Or Supplemental Security Income (SSI?)
income $______________
YES
NO
Unknown
Worker Number
Unknown
4
OUR MONTHLY HOUSEHOLD EXPENSES ARE:
Date
TOTAL COST OF
THE AMOUNT
THE AMOUNT
ITEM
PAID TO
THE ITEM
I PAY
HE PAYS
Rent/House
Full Item Of Need
Payment
$
$
$
Utilities
Housing
$______________
$
$
$
Utility
$______________
Food
$
$
$
Food
$______________
Clothing
Clothing
$______________
$
$
$
5
Earmarked Money
In addition to the amounts in Item 4, he gives me $________________________ each month for:
Unearned Income
(Explain)
6
Number of his dependents who live with my family __________________________
YES
NO
Do you purchase/prepare food together?
7
Do you consider yourself and the unrelated adult male a family?
YES
NO
CERTIFICATION FOR THE CASH AID MOTHER/UNRELATED ADULT MALE
I have been told the rules for the cash aid program for an unrelated adult male who lives with a family who gets cash aid.
I understand that the unrelated adult male must:
-
Help pay each month for living expenses. The amount he pays must be at least as much as it would cost him to live on his own,
according to the standards set by the state; and
-
Sign a statement about his financial arrangements with the cash aid mother he is living with; and
-
Be reported to the district attorney if he refuses to make the required contribution or refuses to sign the required statement.
I understand that I must tell the county when there is any change(s) to the facts on this statement.
I certify that each of the statements given is true and correct to the best of my knowledge and belief. I declare under penalty of
perjury under the laws of the United States and the State of California that the information in this statement is true, correct, and
complete.
Signature of Cash Aid Mother
Date Signed
Signature of Unrelated Adult Male
Date Signed
CW 71 (3/00) REQUIRED FORM - SUBSTITUTE PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF CASH AID MOTHER
AND UNRELATED ADULT MALE (UAM)
You must give the county facts about the financial arrangements when an Unrelated Adult Male (not related to you or your children)
lives in a household that gets cash aid. These rules do not apply to roomers or borders.
The unrelated adult male who lives with you in your home must help pay each month for living expenses. The amount of money he
pays must be at least as much as it would cost him to live by himself. The state has rules for deciding how much this should be.
CASH AID MOTHER’S STATEMENT
An unrelated adult male lives with us.
I give the following facts about an unrelated adult male who lives with me and the arrangements we have entered into.
1
Name of Unrelated Adult Male
(First
M.I.
Last)
COUNTY USE ONLY
Case Name
2
We have lived together since:
Month
Day
Year
Case Number
3
Does he get aid, such as CalWORKs, General Assistance,
Unrelated Adult Male’s gross amount of monthly
Worker Name
Food Stamps Or Supplemental Security Income (SSI?)
income $______________
YES
NO
Unknown
Worker Number
Unknown
4
OUR MONTHLY HOUSEHOLD EXPENSES ARE:
Date
TOTAL COST OF
THE AMOUNT
THE AMOUNT
ITEM
PAID TO
THE ITEM
I PAY
HE PAYS
Rent/House
Full Item Of Need
Payment
$
$
$
Utilities
Housing
$______________
$
$
$
Utility
$______________
Food
$
$
$
Food
$______________
Clothing
Clothing
$______________
$
$
$
5
Earmarked Money
In addition to the amounts in Item 4, he gives me $________________________ each month for:
Unearned Income
(Explain)
6
Number of his dependents who live with my family __________________________
YES
NO
Do you purchase/prepare food together?
7
Do you consider yourself and the unrelated adult male a family?
YES
NO
CERTIFICATION FOR THE CASH AID MOTHER/UNRELATED ADULT MALE
I have been told the rules for the cash aid program for an unrelated adult male who lives with a family who gets cash aid.
I understand that the unrelated adult male must:
-
Help pay each month for living expenses. The amount he pays must be at least as much as it would cost him to live on his own,
according to the standards set by the state; and
-
Sign a statement about his financial arrangements with the cash aid mother he is living with; and
-
Be reported to the district attorney if he refuses to make the required contribution or refuses to sign the required statement.
I understand that I must tell the county when there is any change(s) to the facts on this statement.
I certify that each of the statements given is true and correct to the best of my knowledge and belief. I declare under penalty of
perjury under the laws of the United States and the State of California that the information in this statement is true, correct, and
complete.
Signature of Cash Aid Mother
Date Signed
Signature of Unrelated Adult Male
Date Signed
CW 71 (3/00) REQUIRED FORM - SUBSTITUTE PERMITTED