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INCOME VERIFICATION <br />(for Department of Social Services aid recipients) <br />TO: CALIFORNIA DEPARTMENT OF SOCIAL SERVICES <br />Ladies and Gentlemen: <br />I am receiving assistance through your office. I have applied for a rental unit <br />located in a project with improvements financed by the City of Santa Ana for <br />persons of low income. In connection with my application for a rental unit, I <br />hereby authorize the Department of Social Services to release to <br />the specific information requested below: <br />Date: <br />Signature <br />Caseload Number <br />Name (Print): <br />Case Number <br />Case Worker: <br />1. Number of persons included in budget: <br />2. Total monthly budget $ <br />a) Amount of grant $ Date aid last began: <br />b) Other income. and source: <br />c) Is other income included in total budget? Yes No <br />3. Please specify type of aid (AFDC, FR, Food Stamps, ANB, MediCal, Etc.) <br />4. If recipient is not receiving full grant, please indicate reason: <br />❑ Overpayment due to client's failure to report other income <br />❑ Computation error <br />❑ Other <br />5. Date when full grant will resume: <br />Case Worker's Signature <br />Telephone. District Office: <br />Your very early response will be appreciated. <br />INCOME VERIFICATION <br />Exhibit I: 10 of 11 <br />