The PA 167 Monthly Earnings Report is the Los Angeles County DPSS form you use to declare self-employment income paid in cash when you have no pay stubs, 1099s, or bank records to prove what you earned. You list your gross earnings and hours for the reporting period, sign under penalty of perjury, and return it to your caseworker along with any other documentation your program requires.1Los Angeles County Department of Public Social Services. 63-503.41 Self-Employment Income
When DPSS Asks You to File This Form
DPSS uses PA 167 for people who work for themselves and get paid in cash: rideshare drivers, handymen, house cleaners, swap meet vendors, freelance workers, and anyone else whose earnings do not show up on a stub or tax form.1Los Angeles County Department of Public Social Services. 63-503.41 Self-Employment Income
You do not need PA 167 if your income can be verified another way. Bank deposit records, invoices with payment confirmations, and 1099 forms all substitute for it. Gig platforms like rideshare and food delivery apps generate earnings summaries you can print or screenshot, and those summaries generally qualify as independent verification on their own. Ask your caseworker before filling out PA 167 if you already have documents like these.
What to Put on the Form
Report gross self-employment income, not what you take home. Gross means the total your customers and clients handed you before you subtract anything for gas, supplies, phone, or other business costs. The county applies the appropriate deductions when it calculates your benefit. Writing down your profit instead of your receipts is one of the most common errors, and it can produce the wrong benefit amount.1Los Angeles County Department of Public Social Services. 63-503.41 Self-Employment Income
Put your DPSS case number on the form so it gets routed to your file. List the dates you worked and the amount received for each. Cash income from gig work usually varies day to day, so itemize each payment rather than combining a whole month into one figure. This gives the caseworker enough detail to process the form without calling you back for more.
You sign PA 167 under penalty of perjury. That signature is a sworn statement that everything on the form is true and complete. Check every figure before signing.
Records That Back Up Your Numbers
Since PA 167 exists precisely because no formal paperwork covers your earnings, whatever informal records you keep become the backup for the figures you report. Start a simple log in a notebook or a phone spreadsheet. Note the date, the client or type of work, hours, and the amount paid, and write it down when the payment happens. A contemporaneous log is far more credible than a month-end reconstruction from memory.
If a client will write you a short statement confirming what they paid, that helps too. It doesn’t need to be notarized. Include the client’s name, a description of the work, dates, and payment amount. Text message confirmations of payment and informal receipts also work if your caseworker asks for more.
How to Submit PA 167
Your caseworker will usually hand you PA 167 when your cash self-employment comes up during an application or recertification. You can also pick one up at any DPSS district office.2Los Angeles County Department of Public Social Services. Office Locations Once it’s completed and signed, you have several ways to return it:
- Upload it through BenefitsCal at benefitscal.com. A scan or a clear phone photo works, and you can submit documents even without an account. Accepted formats include PDF, JPEG, PNG, and common document types.3BenefitsCal. Home4BenefitsCal. BenefitsCal Quick Guide – Upload Documents
- Bring it to your assigned district office, or drop it in the office drop box if one is available.
- Call the DPSS Customer Service Center at (866) 613-3777 to ask about mailing instructions for your office.2Los Angeles County Department of Public Social Services. Office Locations
One quirk of BenefitsCal: once you upload a document, it can’t be removed or replaced. Confirm you’re sending the right, signed version before you hit submit.
When the Form Needs to Reach the County
PA 167 itself is a snapshot of one reporting period. The deadline for getting it in depends on which program you’re in.
General Relief
General Relief participants report changes as they happen, not on a monthly form. New earned income of $203 or more, or an increase of $25 or more in any type of income, must be reported within five calendar days of when you learn about it.5Los Angeles County Department of Public Social Services. 40-104 Reporting Responsibilities for General Relief Applicants and Participants You can report in writing, in person, or by phone. If the new income is cash self-employment, PA 167 goes with the notification as the documentation.
CalFresh and Cash Aid on Semi-Annual Reporting
For CalFresh and certain cash aid programs, the county mails you a SAR 7 Eligibility Status Report near the end of your reporting period. Sign it after the last day of the report month and return it by the 5th of the following month.6Los Angeles County Department of Public Social Services. General Relief 40-122 Periodic Reporting Attach a completed PA 167 as your income backup if self-employment cash is part of what you’re reporting.
After You Turn It In
The county reviews your PA 167 with the rest of your file and sends you a Notice of Action in the mail. The notice tells you whether your benefit is changing, staying the same, or ending, and it gives the effective date of any change. Read it when it arrives.
If your figures are incomplete or don’t line up with something else the county has, your caseworker may contact you before making a decision. Answer promptly so your benefits aren’t held up while the county waits.
Good cause can excuse a late report when something outside your control got in the way, such as a hospitalization, a natural disaster, or losing access to your records.5Los Angeles County Department of Public Social Services. 40-104 Reporting Responsibilities for General Relief Applicants and Participants If you’re going to miss a deadline, call your caseworker and explain rather than skipping the report.
Honest Mistakes vs. False Reporting
Because you sign PA 167 under penalty of perjury, deliberately misstating your income is not only a program violation. It can be a crime. Under California Welfare and Institutions Code Section 10980, knowingly making a false statement or concealing income to get benefits you aren’t entitled to is a misdemeanor punishable by up to six months in county jail, a fine of up to $500, or both. If the benefits wrongly obtained exceed $950, the charge can be elevated to a felony carrying 16 months, two years, or three years of imprisonment and a fine of up to $5,000.7California Legislative Information. California Welfare and Institutions Code WIC 10980
An honest mistake is a different situation. If you miscounted cash payments or misunderstood a section of the form, you’ll likely have to repay the overage, but the criminal penalties turn on intent: knowingly and willfully misrepresenting your situation versus a good-faith error.7California Legislative Information. California Welfare and Institutions Code WIC 10980 Overpayments are recoverable regardless of fault; the county reduces future grants to recoup what it paid in error.8Los Angeles County Department of Public Social Services. 44-309 General Relief Overpayments
If any part of the form is unclear, ask before signing. DPSS provides free interpreter services, including American Sign Language, at your district office.9Los Angeles County Department of Public Social Services. Language Services Getting the numbers right the first time is easier than correcting them later.