Submit Date 03/08/2023

Submit Time 04:07 PM

Periodic Report Summary

Programs Food (CalFresh)

Your Information

Main Applicant Manuel Chavez (47)

Which benefits would you like to stop receiving?

Home Phone

Mobile Phone (760) 403-8563

Has your address changed since you last reported? No

Home Address

Mailing Address 15105 CONDOR RD,

VICTORVILLE,California, 92394

What's the effective date of this change?

Income

Job/Income

<span>In this section, we want to know what’s happened

during the month of January?<span><br><br><span>Did No
you, or anyone in your household, get income from a job or
 Earned Income Change

Think about the money you get that doesn’t come from
No
work. Do you think it may change in the next 6 months?

Other Income Change

Will the income you get from any other sources change
No
in the next 6 months?

Expenses

Housing Costs

Did your housing costs change since you last reported? No

Review & Submit

Signature

First Name Nanuel

Last Name Chavez

Date 03/08/2023

Spouse

First Name

Last Name

Date 03/08/2023