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521 East Fourth Street Long Beach, CA 90802 Tel (562) 5706985 Fax (562) 4991052STATEMENT OF INELIGIBLE FAMILY MEMBERS (MIXED FAMILIES) If one or more members of a family elect NOT to contend that
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How to fill out statement of ineligible family

01
Obtain the statement of ineligible family form from the appropriate agency or department.
02
Fill out the form with accurate information regarding the family that is deemed ineligible.
03
Provide specific details about the reasons for the family's ineligibility.
04
Sign and date the form to certify its accuracy and completeness.
05
Submit the completed form to the relevant authority for processing.

Who needs statement of ineligible family?

01
Individuals or families applying for certain benefits or services may need to submit a statement of ineligible family if there are other family members who do not meet the eligibility criteria.
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The statement of ineligible family is a document that identifies any family members who are not eligible for benefits or programs.
The head of household or primary caregiver is required to file the statement of ineligible family.
The statement of ineligible family can be filled out by listing the names of family members who are not eligible for benefits or programs.
The purpose of the statement of ineligible family is to ensure that only eligible family members receive benefits or participate in programs.
The statement must include the names of ineligible family members and a reason for their ineligibility.
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