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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CASH ASSISTANCE PROGRAM FOR IMMIGRANTS CAPI STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS APPLICANT S/RECIPIENT S NAME APPLICANT S SOCIAL SECURITY NUMBER SPOUSE S NAME SPOUSE S SOCIAL SECURITY NUMBER RESIDENCE ADDRESS CITY STREET ADDRESS TELEPHONE NUMBER STATE ZIP CODE MESSAGE TELEPHONE NUMBER PART A - LIVING ARRANGEMENTS Statement of the CAPI appl.

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