List of All CAPI Forms

The following are CAPI forms, to maintain statewide consistency, please do not alter the wording of any of the CAPI forms.

Translated Forms are available.

SOC 111 (8/24) – CAPI Redetermination Coversheet
SOC 452 (6/19) Cash Assistance Program for Immigrants (CAPI) Income Eligibility - Adult
SOC 452A (8/05) Cash Assistance Program for Immigrants (CAPI) Income Eligibility - Child
SOC 453 (8/22) Cash Assistance Program for Immigrants (CAPI) Statement of Household Expenses and Contributions
SOC 454 (4/99) Cash Assistance Program for Immigrants Sponsor to Alien Deeming Worksheet
SOC 455 (1/99) Authorization for State Reimbursement of Interim Assistance
SOC 804 (2/20) Statement of Facts for Determining Continuing Eligibility for the Cash Assistance Program for Immigrants (CAPI)
SOC 807 (7/00) Cash Assistance Program for Immigrants (CAPI) Request for Waiver of Overpayment Recovery - Income/Expenses
SOC 807A (7/00) Cash Assistance Program for Immigrants (CAPI) Request for Waiver of Overpayment Recovery - Without Fault
SOC 809 (10/16) Cash Assistance Program for Immigrants (CAPI) Indigence Exception Statement
SOC 813 (2/25) Cash Assistance Program for Immigrants (CAPI) Indigence Exception Determination
SOC 455 (1/99) Authorization for State Reimbursement of Interim Assistance
SOC 804 (2/20) Statement of Facts for Determining Continuing Eligibility for the Cash Assistance Program for Immigrants (CAPI)
SOC 807 (7/00) Cash Assistance Program for Immigrants (CAPI) Request for Waiver of Overpayment Recovery - Income/Expenses
SOC 807A (7/00) Cash Assistance Program for Immigrants (CAPI) Request for Waiver of Overpayment Recovery - Without Fault
SOC 809 (10/16) Cash Assistance Program for Immigrants (CAPI) Indigence Exception Statement
SOC 813 (2/25) Cash Assistance Program for Immigrants (CAPI) Indigence Exception Determination
SOC 887A (12/20) Cash Assistance Program for Immigrants (CAPI) Nonmedical Out-of-Home Care (NMOHC) Payment Standard Eligibility Determination - Retroactive Certification of NMOHC Payment Standard Eligibility
SSP 14 (9/10) Authorization for Reimbursement of Interim Assistance Initial Claim or Posteligibility Case
SSP 18 (03/24) Notice of Action and Right to Request a State Hearing on Interim Assistance
NA 691 (3/18) Notice of Denial - Cash Assistance Program for Immigrants (CAPI)
NA 692 (9/23) Notice of Change - Cash Assistance Program for Immigrants (CAPI)
NA 693 (9/22) Notice of Approval - Cash Assistance Program for Immigrants (CAPI)
NA 1217 (9/22) Notice of Action - Cash Assistance Program for Immigrants (CAPI) Notice of Overpayment
NA 1218 (9/22) Notice of Action - Cash Assistance Program for Immigrants (CAPI) Notice of Underpayment
NA 1230 (9/22) Notice of Action - Cash Assistance Program for Immigrants (CAPI) Notice of Overpayment - Waiver Approval
NA 1231 (9/22) Notice of Action - Cash Assistance Program for Immigrants (CAPI) Notice of Overpayment - Partial Waiver Approval
- NA 1232 (9/23) Cash Assistance Program for Immigrants Notice of Overpayment - Waiver Denial

Quick Links

Contact Benefits Programs Unit

Contact Adult Programs

Looking for In-Home Supportive Services?

Need Adult Protective Services?

Did you know?
Help with the high cost of food is available! CAPI recipients may be eligible for CalFresh (Food Stamps) or CFAP.Apply on BenefitsCal.com.

Suspect Fraud?
IHSS Fraud Hotline: 1-(888) 717-8302
Help Stop Medi-Cal Fraud and Abuse
Provider Fraud and Elder Abuse complaint line:
1-(800) 722-0432

Fee Restrictions

Health care providers and clinics shall not charge a fee to a patient for filling out any forms related to an IHSS applicant’s eligibility determination or providing information responsive to forms that support a claim or appeal regarding eligibility for a public benefit program (Health and Safety Code Section 123114).
Prohibited form fees should be reported to Adult Programs Division, Policy and Quality Assurance Branch, Policy, and Operations Bureau at (916) 651-5350.