Blank CDSS SAR-7 Template

The CDSS SAR-7 form, also known as the "Semi-Annual Report," is a crucial document used by individuals to report changes in their circumstances while receiving certain public assistance benefits. This form helps the California Department of Social Services ensure that recipients continue to meet eligibility requirements and receive the right amount of assistance. Understanding and completing the SAR-7 form accurately is essential for maintaining your benefits.

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Article Guide

The CDSS SAR-7 form is an important document used in California for reporting changes in income and household circumstances for individuals receiving public assistance. This form is often required for those enrolled in programs like CalWORKs, Medi-Cal, and CalFresh. By completing the SAR-7, applicants help ensure that their benefits are accurately calculated and adjusted based on their current situation. The process typically takes place every six months, and it is crucial for recipients to provide up-to-date information regarding income, employment, and family size. Failure to submit the SAR-7 on time can lead to interruptions in benefits, so understanding its requirements and deadlines is vital. Moreover, completing the form accurately can help individuals receive the assistance they need in a timely manner, ultimately improving their quality of life. Whether you’re new to the process or are renewing your benefits, grasping the essentials of the SAR-7 can make a significant difference.

Form Sample

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

⇩ PDF

Document Specifications

Fact Name	Details
Purpose	The CDSS SAR-7 form is used for reporting changes in circumstances for public assistance programs in California.
Who Uses It	California residents applying for or receiving CalWORKs, CalFresh, and Medi-Cal benefits need to fill out this form.
Frequency of Use	Beneficiaries must submit the SAR-7 form every six months to continue receiving benefits.
Submission Method	The form can be submitted online, by mail, or in person at local county offices.
Governing Law	This form is governed by California state law, specifically under the California Welfare and Institutions Code.
Important Deadline	The SAR-7 form must be submitted by the due date listed on the notice sent by the county office.

Steps to Filling Out CDSS SAR-7

You are about to complete the CDSS SAR-7 form, which is essential for reporting changes in your circumstances for ongoing benefits. Follow these straightforward steps for accurate completion.

Begin with your personal information. Enter your name, address, and case number at the top of the form.
Fill in the household members’ details. List everyone who lives with you, including their names and relationship to you.
Report your income. Provide accurate details regarding your current income sources, including employment, benefits, and any other earnings.
Disclose expenses. Enter any regular monthly expenses, such as rent, utilities, and childcare costs.
Note any changes in circumstances. Indicate any recent changes, like job loss, change in income, or new family members.
Sign and date the form. Make sure you certify that the information provided is correct to the best of your knowledge.
Submit the form. Follow the instructions for submission, whether online or via mail, to ensure timely processing.

More About CDSS SAR-7

What is the CDSS SAR-7 form?

The CDSS SAR-7 form, officially known as the “Semi-Annual Report,” is a crucial document used by California's Department of Social Services. It is designed for recipients of certain benefits, including CalFresh, Medi-Cal, and Cash Aid, to report changes in their circumstances every six months. Completing this form helps ensure that individuals receive the correct amount of benefits based on their current situation.

Who needs to fill out the SAR-7 form?

If you are a participant in programs such as CalFresh, Medi-Cal, or Cash Aid, you are typically required to fill out the SAR-7 form. The requirement usually applies to anyone receiving benefits who has been notified to submit the report. If you are uncertain about your obligations, it's best to check with your local county office.

When is the SAR-7 form due?

The SAR-7 form is generally due six months after your last report. The exact due date will be provided to you when you start receiving benefits. It’s vital to adhere to the deadlines because missing the submission can lead to a suspension or loss of benefits. Ensure you mark your calendar and set reminders.

How do I complete the SAR-7 form?

What happens if I don’t submit the SAR-7 form?

Failing to submit the SAR-7 form on time can result in serious consequences. You risk having your benefits paused or terminated, which can lead to significant hardships. If you miss the deadline, it is advisable to submit the form as soon as possible and contact your local office to discuss your situation.

Can I access the SAR-7 form online?

Yes, you can access the SAR-7 form online through the California Department of Social Services website. There, you can find the form available for download. Additionally, many counties may provide their own resources or online portals where you might complete or submit the form electronically.

What if I have questions while filling out the SAR-7 form?

If you have questions while completing the SAR-7 form, you should reach out for help. You can contact your local county welfare office for assistance. Many agencies also have resources available online, including FAQs and contact numbers to support you. Don’t hesitate to seek help—doing so can make a significant difference in ensuring your report is accurate.

Is there assistance available if I need help with my report?

Yes, assistance is available for those who need help with their SAR-7 report. Community organizations, social workers, and local county offices provide support services. They can guide you through the process, help you understand the requirements, and ensure that you complete the form accurately. Many organizations also offer resources in multiple languages, catering to a diverse community.

Common mistakes

Neglecting to Provide Accurate Personal Information: One common mistake is failing to accurately fill out the personal information section. This includes name, address, and Social Security number. Ensure all details match official documents to avoid processing delays.
Misreporting Income: People often forget to include all sources of income. Whether it's wages, unemployment benefits, or child support, all income sources must be reported clearly to avoid complications.
Failing to Update Changes: If a recipient's situation changes, such as a job loss or a new family member, it’s essential to update the information. Failure to do so can result in overpayments or loss of benefits.
Omitting Required Signatures: Some individuals may overlook the signature section. Every form must be signed to affirm that all information provided is correct and truthful.
Ignoring Documentation Requirements: The form may require certain documents to be submitted alongside it. Not including these can lead to delays in processing and benefit determination.
Not Keeping a Copy: After submitting the SAR-7, it's important to keep a copy for personal records. This can be helpful in case of any disputes or follow-up inquiries regarding your information.
Overlooking Deadlines: Submitting the SAR-7 after the deadline can lead to a loss of benefits. It's crucial to be aware of the timelines and submit all necessary forms on time.
Assuming Help Isn’t Available: Many people believe they must navigate the process alone. It’s important to seek assistance if needed. Whether from family members or professional advisers, this can help ensure accuracy and compliance.

Documents used along the form

The CDSS SAR-7 form, known as the Semi-Annual Report, is a crucial document for individuals and families receiving public assistance in California. However, it's often accompanied by several other forms and documents that help streamline the process and ensure accurate reporting of information. Below is a list of related documents that you may encounter.

CDSS 26 – Application for Food Stamp Benefits: This form is used to apply for food assistance. It collects detailed information about the household composition and financial resources.
CDSS 285 – Declaration of Identity: This document serves to confirm the identity of an individual seeking benefits. It helps to prevent fraud by ensuring that applicants are who they claim to be.
CDSS 928 – CalWORKs and CalFresh Proof of Employment: This form is requested when individuals need to document their work status. It includes information about income and hours worked, essential for benefit calculations.
Verification Documents: Various documents may be required for verification purposes. This includes pay stubs, bank statements, or utility bills to confirm income and residency status.
CalFresh Income Eligibility Test: This form determines if applicants meet the income limits for receiving food assistance. It plays a significant role in the approval process for benefits.
Doctors’ Statements: If medical needs impact the assistance being requested, a doctor may need to provide a statement. This verifies any medical conditions that warrant additional benefits.

Each of these documents plays a vital role in the process of receiving benefits. Understanding what is needed can make the experience smoother for everyone involved. Be sure to gather all necessary documentation to ensure efficient processing of your application and continued assistance.

Similar forms

The CDSS SAR-7 form, used by the California Department of Social Services to report changes in circumstances for public assistance recipients, shares similarities with the Annual Recertification form. Both documents require recipients to provide updated information on their financial status, household composition, and living situation. The Annual Recertification form focuses on verifying eligibility for continuing benefits, much like the SAR-7, which also serves to ensure that recipients still meet the necessary criteria to receive aid.

Another document akin to the CDSS SAR-7 is the Interim Report. This form is typically completed between regular reporting periods, allowing recipients to report significant changes that could affect their benefits. Like the SAR-7, the Interim Report seeks to ensure that the information provided is current and accurate, maintaining compliance with eligibility requirements for assistance programs. Both forms emphasize timely updates to prevent overpayment or underpayment of benefits.

The Personal Affairs Form also has characteristics in common with the SAR-7. This document is often used to collect personal and financial information about an individual or household. Similar to the SAR-7, it aims to gather essential data that helps in assessing eligibility for various assistance programs. Both forms are critical in determining benefit amounts and ensuring that recipients receive the correct level of support based on their circumstances.

Lastly, the Change Report is another document that overlaps with the functions of the CDSS SAR-7. This form is specifically used to communicate changes in a recipient's situation, such as job status, income adjustments, or changes in family size. The Change Report requires detailed information similar to that requested on the SAR-7, and both documents play vital roles in maintaining up-to-date records that affect assistance eligibility and benefit levels.

Dos and Don'ts

When filling out the CDSS SAR-7 form, it is important to approach the task with care. Here’s a list of things you should and shouldn’t do to ensure accuracy and clarity:

Do read the instructions carefully before starting the form.
Do provide accurate and up-to-date information regarding your household's income and expenses.
Do double-check your entries for any spelling or numerical errors.
Do submit the form by the due date to avoid any interruptions in your benefits.
Don't leave any sections blank; provide answers or state 'none' where applicable.
Don't fabricate or exaggerate information; honesty is crucial.
Don't forget to keep a copy of the completed form for your records.

Misconceptions

Misconception 1: The SAR-7 form is only required for new applications.

This form is essential for ongoing eligibility and must be submitted regularly, typically every six months, even after an initial application has been approved.

Misconception 2: Completing the SAR-7 form is optional.

It is a mandatory requirement for maintaining benefits. Failing to submit the SAR-7 can result in the suspension or termination of assistance.

Misconception 3: The SAR-7 form is overly complicated and hard to complete.

While the form may appear lengthy, it contains straightforward questions aimed at gathering necessary information. Many resources are available to assist applicants with the process.

Misconception 4: Submitting the SAR-7 form late is acceptable.

Timely submission is crucial. Late submissions may lead to interruptions in benefits, emphasizing the importance of adhering to deadlines.

Key takeaways

Completing the CDSS SAR-7 form accurately is essential for maintaining your benefits. Ensure that all personal and household information is up to date.
Submit the form on time to avoid interruptions in benefits. Typically, the SAR-7 must be submitted every six months.
If you have changes in your financial situation, report them immediately. This could affect your eligibility and the amount of benefits you receive.
Always keep a copy of your submitted form for your records. This can be useful for future reference or if any issues arise.