Sample Gift Letter

Todays Date: ________________________

Healthy Families/Medi-Cal for Families
P.O. Box 138005
Sacramento, CA 95813-8005
Dear Healthy Families and Medi-Cal for Families,
I, ________________________________, give _________________________________
(person giving the gift income)

(person receiving the gift income)

_$_____________ per ________________________________________________ as a gift.

(amount given)

(how often gift is given [weekly, every 2 weeks, twice month, monthly])

Sincerely,
____________________________________
Signature of person giving the gift income

To be filled out by person applying for Healthy Families:

Name:

________________________________________________

Address: ________________________________________________

Telephone Number: _______________________________________

FMN# (If you have it): ______________________________________

Gift Income Letter Rev. 01/2008