SFN 1681, Near Zero Income Worksheet 415-65-20

(Revised 10/00 ML #2629)

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SFN 1681 is an optional form which may be used in place of or as a supplement to case narrative required on 415-05-35(e) when a household reports zero or near zero income.  The "Near Zero Income Worksheet" may be completed by the applicant, county staff, or both.

 

Another potential use of Form 1681 is to provide an interviewing tool to:

 

• Identify unmet needs and potential service and/or economic assistance referrals.
• Identify discrepancies in income/asset/expense reporting.
• Document a realistic appraisal of budgeting needs which may encourage an applicant to follow through on referrals.

 

Instructions are printed on the back of the form.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.