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SECTION 2 Continued

24 Has any one ever received

cash aid, SSI, Food Stamps or Medi-Cal?

Adult 1/Self

Yes No

Adult 2

Yes No

Child 1

Child 2

Child 3

Yes No

Yes No

Yes No

If “Yes,” under what name?

25

Medi-Cal benefits BIC card number, if you have it:

26

Wants medical benefits?

27

Do you own or are you buying a home outside California?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

SECTION 3

Answer for all children in Section 2.

Is Mother:

Employed

Is Mother:

Employed

Is Mother:

Employed

Is Mother:

Employed

Disabled

Unemployed

Disabled

Unemployed

Disabled

Unemployed

Disabled

Unemployed

Father’s Name:

Child 2

Child 3

Unborn

Mother’s Name:

Mother’s Name:

Mother’s Name:

28

Child 1 Mother’s Name:

Deceased Absent Father’s Name:

Decease

d Absent

29

Father’s Name:

Deceased Absent Father’s Name:

Is Father:

Employed

Disabled

Unemployed

Deceased

Absent

Is Father:

Employed

Disabled

Unemployed

Deceased

Absent

Deceased Absent

Is Father:

Employed

Disabled

Unemployed

Is Father:

Disabled Decease

Employed Unemployed d Absent

SECTION 4

List all income/money received by persons listed in Section 2.

30

NAME OF PERSON RECEIVING INCOME/MONEY

S O U R C E O F I N C O M E / MONEY RECEIVED (Employment, social security) 3 1 3 2

HOW MUCH INCOME/MONEY IS RECEIVED

33

HOW OFTEN INCOME/ MONEY RECEIVED

(Monthly, bimonthly, weekly, biweekly, daily)

TYPE OF PAYMENT

34

NAME OF

35 MONTHLY

36

CHILD CARE OR

37 AGE

38

NAME OF

39 MONTHLY

YOUR FAMILY MAKES

PERSON WHO PAYS

AMOUNT PAID

DEPENDENT CARE

PERSON WHO PAYS

AMOUNT PAID

SECTION 5

Give information about the listed expenses/cost paid by all persons listed in Section 2.

Child Support

(List child’s or dependent’s name)

1.

Alimony

2.

Other Health Insurance Premium

3.

Medicare Premium

4.

MC 210 08/01 APPLICATION

A2

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