Send
Completed
Form 224
To
Metfro.  No.   District
Mc-ripofco   Sub   Ci*ice
5026   Santa   Monko  BivA
Los Angeles 19» Calif*
Name and
Address of
County Welfare
Department
INFORMATIONAL AND INSTRUCTIONAL SHEET FOR RESPONSIBLE RELATIVES
FORM AG 224
The eligibility of your parent for Old Age Security is under consideration and the following information is important to
you as a responsible relative.
Under the law, adult children of persons receiving Old Age Security are required to contribute to the support of such
recipients, if they are able to do so, and this agency is required to determine your ability. The amount of the required
contribution is determined according to a scale based on the relative's income and the number of his dependents.
In order to make a preliminary determination, we are asking you to complete the enclosed brief form and return it to us
within 15 days. If, from the information you provide us on this form, it seems clear that you would not be required to make
a contribution, it may not be necessary for us to contact you further. However, if it appears you might be expected to
make a contribution, we will ask you to submit additional information. In such case, we will send you another form to be
used for this purpose.
Whether you have a liability or not we must know what contributions, if any, you plan to make to the support of the recipient, as such contributions must be taken into consideration in determining the amount of Old Age Security to which the
recipient is eligible. Accordingly, information concerning contributions is also requested on the form. In completing the form
please indicate the amount of any cash contributions and specify the type of any other contributions you plan to make such
as free rent, free board, etc.
The following definitions and general information are important and it is essential that they be observed by you in completing the enclosed form.
GROSS INCOME
Gross income is the total amount of income, regardless of form, before subtracting any expenses or before any deductions
are made for Social Security taxes, other insurance, or retirement contributions, personal income tax withholdings, stock
or bond deductions of any kind.
If you are a married son the gross income you are required to report is the sum of 1) your own earnings; 2) your separate income from property or any other source, and all Community income except earnings of your spouse.
If you are a married daughter the gross income you are required to report is the sum of 1) your own earnings; 2) your
separate income from property, pensions, or any other source.
If you are a single, divorced, widowed or separated adult child (son or daughter) you are required to report your total gross
income from all sources.
DEPENDENT
Include yourself but not the applicant or recipient when reporting number of dependents.
For purposes of liability determination, your dependent is a person related to you by blood/marriage or adoption, whose
income is insufficient to meet his needs and for whom you provide the major portion of support in or out of the home. A person with income of $lOO a month or more is not generally considered a dependent.
Information concerning your spouse's income is required when you claim anyone other than yourself as a dependent. Your
spouse's income is not included in the total of your income but is considered in reviewing your claim of dependents. If both
you and your spouse contribute to the family income, your combined dependents are to be divided between you in accord
with the percentage of the total family income each of you contributes.
Be sure to complete each item on the form and check appropriate boxes. Then sign the form and mail, within 15 days, to
the address above.
FORM AG 224 INSTRUCTIONS SEPTEMBER 19*_k A spo
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