Welfare and Institutions Code section 14021.53
(1)
Court-ordered payments, such as child support, fines, debts, restitution, or other payments.(2)
Housing-related expenses, such as rent, mortgage, insurance, utilities, or other obligations.(3)
Transportation costs, such as any related expenses, including automobile payments or automobile insurance payments.(4)
Insurance coverage should also be noted if it produces either an expense or benefit to the client.(1)
The amount box indicates the client’s fee according to his or her location on the sliding scale.(2)
The adjusted client monthly fee box is to be filled only if the fee to be charged differs from the fee indicated by the client’s location on the sliding scale.(3)
If the fee is adjusted from what the sliding scale would indicate, a reason for the adjustment must be provided. (Valid reasons might include extraordinary medical expenses for a client suffering from HIV/AIDS, etc.)
Source:
Section 14021.53, https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC§ionNum=14021.53. (accessed Apr. 24, 2025).