Fill in a Valid CDSS SAR-7 Template

The CDSS SAR-7 form is an essential document used in California for reporting changes in a household’s circumstances related to public assistance programs. This form helps ensure that individuals and families receive the appropriate level of support. Completing it accurately is crucial for maintaining benefits, so make sure to fill out the form by clicking the button below.

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The CDSS SAR-7 form is an essential tool for individuals and families receiving assistance in California. It plays a crucial role in the state's safety net programs, helping to ensure that benefits are not only distributed accurately but also reflect the current needs of recipients. This form assists in reporting changes in personal information, income, and household circumstances. By providing updated information, recipients contribute to a more efficient benefits system and avoid potential overpayments. Completing the SAR-7 form accurately is vital, as it affects eligibility for ongoing assistance. Understanding the nuances of this form can empower individuals to navigate the process effectively and maintain their crucial support services.

CDSS SAR-7 Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES

SAR 7 ELIGIBILITY STATUS REPORT

REPORT MONTH ___________

TO KEEP YOUR BENEFITS COMING ON TIME, PLEASE SIGN THE FORM AFTER ___________ 1st AND RETURN IT BY _________5th

SUBMIT MONTHSUBMIT MONTH

NEED HELP? (County Specific instructions w/county url)

CASE NUMBER HERE

Worker Name:

[DIST. ID HERE]

Worker Phone:

County:

Street address:

City, State, Zip Code

BAR CODE:

Check the box if you would like to STOP getting any of the following: ■

■

STOP my CalWORKs ■ STOP my CalFresh STOP my Medi-Cal

1.Has anyone moved into or out of your home (including newborns) or did you move in with someone else since you last

reported?		■ Yes		■ No (If yes, complete the section below)

	Date of Move				Name	Date Of Birth		Relationship To	Regularly Purchase And
	(mm/dd/yy)				(First, Middle, Last)			You	Prepare Food Together?
■ In	■ Out	/	/			/	/		■ YES ■ NO
■ In	■ Out	/	/			/	/		■ YES ■ NO
■ In	■ Out	/	/			/	/		■ YES ■ NO

2. Have there been any changes to your address since you last reported? ■ Yes ■ No (If yes, complete the section below) New Address:___________________________________________________________________ Date Moved: __________________

Mailing Address (if different than above)____________________________________________________________________________

3.If you have moved since you last reported please fill out the section below:

Your rent or mortgage per month now?

If paid separately, your property taxes and home insurance per month now?

Do you have utility costs that are not included in your rent or mortgage payment? If so, check which ones:

■ Phone ■ Trash

■ Water

■ Electric/Gas

■ Other heating or cooling costs

4.CalWORKs only: Is anyone in your home:

A.Running from an outstanding warrant?

B.Found by a court to be in violation of probation or parole?

■ Yes ■ No (If yes, complete the section below)

Name of person

A or B

from above

In what state was the warrant issued,

or did violation happen?

Date of warrant or violation

5.Medical Costs: If anyone who gets CalFresh and is 60 years old or older, or disabled, had an increase in medical costs please complete the section below and attach proof:

Who had the change?

Amount of increase:

6.Child Support: Did anyone who gets CalFresh have a change in the amount of child support they have to pay since they last reported? ■ Yes ■ No If yes, complete the section below and attach proof.

What was the amount paid in the Report Month? $__________. Who paid support?_______________________________________

7.Dependent Care: If anyone who gets CalFresh and either works, is looking for work, or is going to school, had an increase in out-of-pocket dependent care costs since they last reported, please complete the section below and attach proof:

What was the amount paid out-of-pocket in the Report Month? $__________

Who paid: _________________________________ List dependent(s): _________________________________________________

8.Did anyone: Get, buy, sell, trade or give away any property, land, homes, cars, bank accounts, money, payments (such as lottery/casino winnings, back benefits from social security), or other property items since last reported?

■ Yes ■ No (If yes, complete the section below and attach proof. If you need more space, attach a separate piece of paper).

Who?

Type of Property?

When?

Amount/Value?

■	Bought ■ Sold ■ Gave Away	■
■	Got as a gift ■ Traded ■ Won	■

Spent

Other

SAR 7 (12/14) ELIGIBILITY STATUS REPORT - FOR CASH AID AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED

PAGE 1 OF 2

■ Yes

9. Did anyone get income from employment in the Report Month? ■ Yes ■ No (If yes, complete the section below and attach proof). The Report Month is listed at the top of the first page. List each job for each person who works. If you need more space attach a separate piece of paper. Examples include babysitting, salary, self-employment, sick pay, tips. etc. If you lost your job, attach proof.

		Job #1		Job #2		Job #3
Name of person who got income:

Source of income/Employer name:					Self-employed, check here ■
	Self-employed, check here ■		Self-employed, check here ■		Self-employed, check here ■
How often paid:	■ Weekly	■ Biweekly ■ Other	■ Weekly	■ Biweekly ■ Other	■ Weekly	■ Biweekly ■ Other
How often paid:	■ Monthly	■ Twice monthly	■ Monthly	■ Twice monthly	■ Monthly	■ Twice monthly
	■ Monthly	■ Twice monthly	■ Monthly	■ Twice monthly	■ Monthly	■ Twice monthly

Gross amount of income they got in the	$		$		$
report month:
report month:	DATE(S) RECEIVED:		DATE(S) RECEIVED:		DATE(S) RECEIVED:

Hours worked per month:

10. Will there be any changes to your income from employment in the next six months (including income listed in #9)?

■ Yes ■ No (If yes, explain here and attach proof). Examples: Stopping or starting a job; increase or decrease of income; changes in hours; quitting a job or going on strike; change in how often you are paid.

11. Did anyone get money from any other source in the Report Month: ■ Yes		■ No (If yes, complete the section below and attach
proof.) The Report Month is listed at the top of the first page. Examples include: Social Security, Unemployment Compensation,
Veteran’s Benefits, State Disability Insurance (SDI), Child/Spousal Support, Worker’s Compensation, Loans/Gifts, Earned/Unearned
Housing, Utilities, Food, etc. If you no longer get money from a source you previously reported, attach proof.
Name	Source of income		One time payment or monthly	How much
				$
				$
				$

12. Will there be any changes to money received from any other source in the next six months (including money listed in #11)? ■ No (If yes, explain here and attach proof). Examples of changes: An increase or decrease in income or benefits, or if

you will start or stop getting income or benefits.

13. CalWORKs only: Have any of the following happened to anyone in your home since you last reported? ■ Yes ■ No (If yes, check below and attach proof):

■Family Change (Married, divorced, separated, entered into a California Registered Domestic Partnership (RDP), have a non-California Domestic Partnership (DP), ended a DP or RDP, became pregnant, or is no longer pregnant?)

■

Job/Employment (Start, stop, quit a job, started a business or went on strike?) Disability (Became disabled or recovered from a disability or major illness?)

Immigration (Citizenship or immigration status change, or got a new card, form, or letter from USCIS (INS)?) Insurance (Started, stopped, or changed health, dental, or life insurance benefits, including MEDICARE?) Custody (Any change in the amount of time you care for/have custody of your children?)

In-Home Support Services (Started or stopped getting services?)

School Attendance

For Age 18 or older student - started or stopped school/college? (You may be able to claim costs for books, school transportation, etc.)

■Someone paid for all of my housing, food, clothing or utility costs. (please explain) _______________________________

■Other_________________________________________

Please read carefully, sign, and date.

By signing this form:

•I understand and certify, under penalty of perjury, that all my answers on this report are correct and complete to the best of my knowledge.

•I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000. I may have to pay back benefits if I was not eligible to them. The first time I break the rules on purpose I will not be able to get CalFresh for one year; the second time two years; and after the third time I will not be able to get CalFresh again.

•I understand and agree to give copies of all documents needed to complete my semi-annual report.

•I understand that in some instances, I may be asked to give consent to the County to make whatever contacts are necessary to determine eligibility.

CERTIFICATION - FRAUD WARNING

I UNDERSTAND THAT: If on purpose I do not report all facts or give wrong facts about my income, property, or family status to get or keep getting aid or benefits, I can be legally prosecuted. I may also be charged with committing a felony if more than $950 in Cash Aid, and/or CalFresh is wrongly paid out as a result of such an action. I have received a copy of the Instructions and Penalties for the SAR 7 Eligibility Status Report for Cash Aid and CalFresh.

YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE REPORT MONTH OR IT WILL BE CONSIDERED INCOMPLETE.

I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this report are true and correct and complete.

WHO MUST For Cash Aid: You and your aided spouse, registered domestic partner, or the other parent (of cash-aided children) if living in the home.

SIGN BELOW: For CalFresh: The head of household, a responsible household member, or the household's authorized representative.

SIGNATURE OR MARK

DATE SIGNED HOME PHONE

CONTACT/CELL PHONE

☛	(	)	(	)
☛
SIGNATURE OF SPOUSE, REGISTERED DOMESTIC PARTNER, OR OTHER	DATE SIGNED SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON				DATE SIGNED
PARENT OF CASH AIDED CHILD(REN)	COMPLETING FORM
☛	☛

SAR 7 (12/14) ELIGIBILITY STATUS REPORT - FOR CASH AID AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED	PAGE 2 OF 2

Click for CDSS SAR-7 File

File Breakdown

Fact Name	Details
Purpose	The CDSS SAR-7 form is used to report changes in circumstances for individuals receiving public assistance in California.
Frequency	Recipients must complete the SAR-7 form every six months to continue receiving benefits.
Eligibility	The form applies to individuals enrolled in the CalFresh, CalWORKs, or other state welfare programs.
Governing Laws	The use of the SAR-7 form is governed by California Welfare and Institutions Code sections 10850 and 11265.
Submission Method	Completed forms can be submitted online, by mail, or in person at local offices.
Required Information	The form requests details about income, household changes, and expenses to assess continued eligibility.

Guide to Using CDSS SAR-7

Once you have the CDSS SAR-7 form ready, it's crucial to fill it out accurately. Completing this form promptly will help ensure that your application is processed without unnecessary delays. Follow the steps below to ensure everything is done correctly.

Begin with your personal information at the top of the form. Fill in your name, address, and contact details.
Provide information about your household members. List their names, ages, and relationships to you.
Complete the income section. Report all sources of income for each household member, including wages, Social Security, or any additional benefits.
Next, detail any expenses. Include rent or mortgage payments, utilities, and any other monthly bills.
Answer all questions regarding any assets you may have, such as savings accounts, vehicles, or property.
Review the declaration at the end of the form. Sign and date it to certify that all information provided is accurate to the best of your knowledge.
Make a copy of the completed form for your records before submitting.

By following these steps, you will ensure that the CDSS SAR-7 form is filled out correctly and submitted on time. Prompt and accurate submission can lead to smoother processing of your application.

Get Answers on CDSS SAR-7

What is the CDSS SAR-7 form?

The CDSS SAR-7 form is a document used by individuals and families in California to report changes in their circumstances while receiving public assistance benefits. It is officially known as the "Semi-Annual Report" and primarily serves to ensure that recipients continue to meet the eligibility requirements for programs such as CalWORKs, Medi-Cal, or CalFresh. This form helps the California Department of Social Services (CDSS) assess ongoing needs and make necessary adjustments to benefits based on current information.

Who is required to submit the SAR-7 form?

If you are receiving certain benefit programs such as CalFresh, CalWORKs, or Medi-Cal, you are generally required to submit the SAR-7 form. Most recipients need to complete this form every six months to report any changes in income, household composition, or other relevant factors. Failing to submit the form may result in a suspension or termination of benefits.

What information is required on the SAR-7 form?

The SAR-7 form collects critical information in various areas, including:

Name and address of the household members
Income details, including wages, benefits, and any other sources
Changes in household size, such as additions or households leaving
Changes in expenses, such as monthly rent or childcare costs

Accurate reporting of this information is essential to ensure continued eligibility for benefits and to determine any changes in the amount of assistance provided.

How do I submit the SAR-7 form?

You can submit the SAR-7 form in several ways. The most common methods include:

Online through your local county welfare department's portal.
By mailing the completed form to your county office.
In person at your local county welfare office.

Each county might have specific guidelines for submission, so it is advisable to check with your local office for any unique requirements.

What happens after I submit the SAR-7 form?

Upon submission of the SAR-7 form, your local county welfare office will review it to determine your ongoing eligibility. They may request additional information or documentation if clarification is needed. Typically, after the review, you will receive a notice regarding any changes in your benefits or instructions for the next steps. It's essential to respond promptly to any requests for information to avoid delays in your benefits.

What if I miss the deadline to submit the SAR-7 form?

Missing the deadline can result in significant consequences, including delays or loss of benefits. If you realize that you have missed the submission date, it’s crucial to act quickly. Reach out to your local county welfare office to explain your situation. They may provide options for reinstating your benefits or accepting your late submission, but prompt communication is key in these cases.

Can I appeal a decision made based on the SAR-7 form?

Yes, if you disagree with a decision made regarding your benefits after the SAR-7 review, you have the right to appeal. You will typically receive information on how to file an appeal along with the notice of decision. The appeal process allows you to present your case and provide additional evidence if necessary. Ensure that you adhere to the deadlines for filing an appeal to maintain your rights.

Where can I find assistance with completing the SAR-7 form?

If you need help completing the SAR-7 form, numerous resources are available. You can contact your local county welfare office for guidance or assistance. Additionally, nonprofit organizations and legal aid services in your area can provide support. They often offer workshops or one-on-one assistance to help individuals navigate the form effectively.

Common mistakes

Completing the CDSS SAR-7 form can feel daunting, but being mindful of common mistakes can ease the process. One mistake people often make is not providing accurate information about their income. It's crucial to report all sources of income, including wages, self-employment earnings, and even benefits from other programs. Underreporting income, even by accident, can lead to complications down the line.

Another frequent pitfall is failing to report changes in household size or circumstances. If someone moves into or out of the home, or if there’s a major life event like marriage or divorce, this must be updated promptly. Ignoring these changes can lead to incorrect eligibility determinations and potential delays in assistance.

Many individuals overlook the importance of completing all sections of the form. Each part is designed to gather specific information, and leaving sections blank can raise red flags. If an individual isn't sure about a section, it's advisable to ask for assistance rather than skipping it altogether. Omissions can lead to processing delays.

Time management is another factor to consider. People sometimes forget to submit the SAR-7 by the deadline. It’s essential to note the due date and plan ahead to deliver the form on time. Late submissions may lead to a lapse in benefits and additional stress.

Inadequate documentation is a common issue as well. The form often requires supporting documents to validate reported income and expenses. It's better to over-prepare and include copies of necessary paperwork, such as pay stubs or bank statements, than to risk having an insufficient application.

Lastly, not reading the instructions carefully can result in confusion. The instructions are there for a reason and can clarify how to correctly fill out each section. Taking a moment to understand the guidelines can save time and prevent mistakes, ultimately leading to a smoother application experience.

Documents used along the form

The CDSS SAR-7 form, or the Semi-Annual Report, is a crucial document in California's public assistance system. It aids in the ongoing assessment of eligibility for benefits to ensure that recipients' circumstances remain unchanged. Accompanying the SAR-7 form are several other important forms and documents, each serving a specific purpose in the benefit application and renewal process. Below is a concise overview of these additional forms.

CDSS 370 (Declaration of Citizenship Status): This form verifies the citizenship or immigration status of individuals applying for benefits. It ensures compliance with federal and state laws regarding eligibility.
Verification of Income: Applicants must provide evidence of any income received, such as pay stubs, tax returns, or bank statements. This documentation helps determine the correct benefit amount.
CDSS 720 (Notice of Action): This document is used to communicate decisions made regarding benefits, including approvals or denials. It outlines the details of the decision and informs recipients of their rights to appeal.
CDSS 19 (Food Stamp Application): For applicants seeking food assistance, this form collects basic information and identifies need based on household size and income.
Employment Verification: Employers may be contacted to confirm employment status and income for individuals applying for aid. This process ensures accuracy in reporting.
Medical Verification: Those needing health-related benefits are often required to submit documentation from healthcare providers, verifying medical conditions and eligibility for services.
Housing Verification: This includes leases or rent receipts to demonstrate living arrangements and expenses, which can impact a household’s financial picture.
CDSS 216 (Child Support Malpractice Form): Families receiving benefits may need to document child support arrangements. This form captures details about child support payments and obligations.

Each of these documents plays a vital role in the evaluation and continuation of public assistance. By accurately completing and submitting these forms, applicants contribute to a clearer understanding of their needs and eligibility, ultimately fostering a more effective social safety net.

Similar forms

CalFresh Application Form (CF 285): This document assesses eligibility for food assistance under the CalFresh program. Like the SAR-7, it requires applicants to provide personal information and details about income and expenses.
Application for Benefits (SAWS 2): Similar to the SAR-7, this form is used to apply for various social services programs. It collects applicant information and helps determine eligibility for assistance.
Semi-Annual Report (SAR 7): Although it shares a name with the SAR-7, this document details ongoing eligibility and needs analysis for ongoing cases. It focuses on income, household size, and changes that may impact assistance.
Annual Redetermination Form: This form is used to re-evaluate a beneficiary's eligibility for benefits annually. It requires updated personal information, similar to how the SAR-7 captures changes over time.
Verification of Employment and Income Form: This document serves to verify income sources and employment status. It parallels the SAR-7 in that it collects financial information necessary to assess continued eligibility for benefits.

Dos and Don'ts

When filling out the CDSS SAR-7 form, it is important to follow certain guidelines to ensure accuracy and completeness. Below is a list of recommended practices and common pitfalls to avoid.

Do: Read all instructions carefully before beginning to fill out the form.
Do: Provide accurate and current information regarding your income and household status.
Do: Double-check all entries for any errors or omissions.
Do: Sign and date the form at the end of the completion process.
Do: Submit the form before the deadline to avoid any disruption in benefits.

Don't: Rush through the form; take the necessary time to ensure accuracy.
Don't: Leave any required sections blank; all fields should be completed.
Don't: Use unfamiliar terminology or abbreviations that might confuse reviewers.
Don't: Submit the form without keeping a copy for your records.

By adhering to these dos and don’ts when filling out the CDSS SAR-7 form, individuals can help facilitate a smoother review process and maintain their eligibility for necessary benefits.

Misconceptions

The CDSS SAR-7 form is a vital document used in California for reporting changes in circumstances for certain public assistance programs. Unfortunately, there are several misconceptions surrounding it. Below is a list clarifying these misunderstandings.

The SAR-7 form is only for certain programs.
Many believe that the SAR-7 is exclusive to specific assistance programs. In reality, it's primarily used for the CalWORKs and CalFresh programs but may apply to others as well.
You can submit the form at any time.
Some think that the SAR-7 form can be submitted whenever they choose. However, it must be submitted during a specified reporting period, typically every six months.
Filling it out incorrectly has no consequences.
This belief is dangerous. Incorrectly completing the form can lead to delays in benefits or overpayments, which recipients may have to repay.
It's only about income.
While income is a significant part of the SAR-7, other factors such as household size, residency changes, and expenses are also important and should be reported.
You don’t need to report temporary changes.
Some individuals think they can ignore short-term changes. However, the SAR-7 requires reporting all changes, whether temporary or not, to ensure accurate benefit calculations.
Submission of the form is the last step.
After submitting the SAR-7, further action may be required. Applicants might need to provide additional documentation or clarification.
Once submitted, you won’t hear back.
People often assume that submission means silence. In reality, recipients are generally contacted if there are issues or if further information is needed.
It’s the same as other forms.
Those thinking the SAR-7 is just like other application forms should reconsider. It has specific requirements and timing that might differ from other documentation.
There’s no online submission option.
Many assume the form cannot be submitted online. In fact, California allows for electronic submission, making it easier and quicker for recipients.
You can ignore the deadline if you inform them beforehand.
This misconception can lead to complications. While it’s good to communicate about potential delays, missing the deadline without proper submission can result in loss of benefits.

Understanding these misconceptions can help individuals effectively navigate the requirements surrounding the CDSS SAR-7 form and ensure they remain compliant with the necessary reporting obligations.

Key takeaways

The CDSS SAR-7 form is an essential document for individuals and families seeking assistance through California's public benefits programs. Understanding how to fill it out correctly can make a significant difference in your access to benefits. Here are some key takeaways:

The CDSS SAR-7 form is used to report changes in circumstances, such as income or household composition, that may affect your eligibility for benefits.
Accurate and complete information is crucial; any discrepancies can delay the processing of your benefits.
Deadlines matter. Submit the SAR-7 within the specified timeframe to avoid a lapse in benefits.
Remember to keep copies of all submitted forms. This ensures you have a record in case any issues arise.
Utilize assistance from local agencies or community organizations if you need help completing the form.
It's important to report all sources of income, even if you believe they won't affect your eligibility.
Be honest about your household composition. Include everyone who lives in your home, as this can impact your benefit calculation.
Regularly review your benefits and the SAR-7 requirements, as policies can change and may affect your circumstances.

By keeping these points in mind, you can navigate the application process more confidently and ensure that you maintain your eligibility for necessary support services.