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Because you get CalWORKs, you must report within 10 days when your TOTAL income reaches a certain level. You must report anytime your household’s total monthly income is more than your current Income Reporting Threshold (IRT). Your family size is _____________ Your current income is $_____________ Your CalWORKs IRT is $_____________ How to report? If your total income is over the IRT amount listed above, you must report this to the County within 10 days. You can report this information to the County by calling the County or reporting it in writing. By “total monthly income” we mean: [ Any money you get (both earned and unearned). [ The amount before any deductions are taken out. (Examples of deductions are: taxes, Social Security or other retirement contributions, garnishments, etc.) What will happen? [ Your benefits may be lowered or stopped based on income over your IRT. [ Your IRT may change when your income changes or when someone moves in or out of your home. [ The County will let you know in writing each time your IRT changes. [ You also need to report during your annual redetermination/recertification (RD/RC) all income the RD/RC form asks about, even if you already reported that money. Penalty for not reporting If you do not report when your income is more than your household’s IRT limit you may get more benefits than you should. You must repay any extra benefits you get based on income you do not report. If you do not report on purpose to try to get more benefits, this is fraud, and you may be charged with a crime. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REPORTING CHANGES FOR CalWORKs AND CALFRESH CASE NAME: CASE NUMBER: WORKER NUMBER: Because you get CalWORKs, you MUST ALSO report the things below within 10 days of when they hap- pen: 1. Anytime someone moves into or out of your household. 2. Anytime someone joins, or is in your household, who is in violation of a condition of probation or parole. 3. Anytime someone joins, or is in your household, who is running from the law. 4. Anytime you have an address change. If you get CalFresh, you MUST report the things below within 10 days of when they happen: 1. Anytime someone moves into or out of your household. 2. Anytime you have an address change. 3. You have a change in the source of income including starting, stopping or changing jobs. 4. Earned income changes by more than $100. 5. Unearned income changes by more than $50 (except for CalWORKs or General Assistance). 6. Rent or utility costs change (only if you move). 7. Any change in the amount of any legally obligated child support. 8. If you are an Able Bodied Adult Without Dependents (ABAWD), you must report any time your work or training hours drop to less than 20 hours a week or 80 hours a month. Voluntarily reporting information You may also voluntarily report changes to the County anytime. Reporting some changes may get you more benefits. For example: G Someone in the house becomes pregnant. G Someone on cash aid has a special need, such as: a pregnancy, a special diet prescribed by a doctor, household emergency, etc. G For CalFresh, if someone disabled or age 60 or older has new or higher out of pocket medical costs. AR 2 CR (3/15) REPORTING CHANGES FOR CALWORKS AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED