Page 89

Handbook

FOOD STAMP HANDBOOK _.H-ORMS AND INSTRUCTIONS

63-1230 (Cont.)

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

62-1230

DFA 377.5 (12/83)

Stata of California Heath and Wellare Agency

FOOD STAMP HOUSEHOLD CHANGE REPORT

INSTRUCTIONS:

You must report changes in your household circumstances within 10 days of the time you learn of any change. You may use this form to report changes of you may report changes in person or by calling the number below Hf you use these forms, you only have to complete the sections that apply to the changes you are reporting. you have any questions about your reporting responsibilities or any doubt about needing to report a change, please contact your worker.

Depariment of Social Services

Worker: Phone:

G) INCOME CHANGES A

| YES oO YES

Did the tots! amount of income received by your household increase of decrease by more than $257 1 YES, complete 1 below.

B. Did the source of income received

by any household member change or did anyone bagin receiving income from # new source? If YES, compteteQ)C below.

€. f¥ES 1071)A or(9)8 above, enter all income received by your Nousehoid. Attach paysiubs or other proof of earnings. For ail other income attach proof when a change is Feported. if anyone is self-empioyed, list business expenses an a seperate sheet of paper and attach proof of income and expenses. Name Source (If Earnings, List Name of Employer) [Amount (Before Deductions! How Often Received? | Dats of Chance 1. 8 2. 5 3. 6 (2) HOUSEHOLD COMPOSITION CHANGES. i Change 28 Date of Chance 11 YES, give name of person snd explain change. A._Did anyone move into your home, including 3 newborn? 8. Did anyone move out of your home or dia? &._Dig anyone get married? D._Did anyone become disabled or recover from a disability? E,_Did anyone turn age 607 F._Did anyone get a new Social Security Number” !f YES, attach proof.

RESOURCE CHANGES: : A,_Did anyone buy of get 8 licensed vehicle? If YES, complete section below: Vehicie Owner Year and Class Make and Model

0 YES

Amount Owed

Estimated Value

6 8 8, Did the total of your househoid’s cash on hand, money ina checking and/or savings account, stacks, bonds, ete. reach or exceed $1500? YES, cornpiete section below:

Cl NES

Liet Rach ttem

Amount Bate of Change 4 $ 2, ‘ § 2. 5

MEDICAL EXPENSE CMANGES

Did the total amount of medical expenses for a hausehold member who is disabled or age 60 ar older increase of decrease by more than $257 if YES, attach receipts and complete section below:

Who Had the Expense?

C) yes

Amount

Type of Expense Amount Who Had the Expense? Type of Expense

1 $ 3. §

2. & 4 ‘ $

“Disclosure of a Social Security Number {SSAI is required by the Food Stamp Act of 1977. as amended by Public Law 97-98, for each food stamp housenoic inember. These SSNs will be used to chack identity, prevent duplicate participation and 1o make changes, The SSNs and any other information provided. wil! aisc be used in computer matching and program reviews or audits to ensure issuance of benefits to eligible individuals participating in the Food Stame Program of other federal assistance programs: suc as: school lunch, AFDC or Medi-Cal Fraudulent participation in the Food Stamp Program may result” criminal or civit action or administrative claims, Refusal io provide an SSN will resull in disqualification of the individual for whom it is not prownec

DFA 277.6 (12 83) Reguued Form No Substitutes Permuttedt

CALIFORNIA-DSS-MANUAL-SS

issue 647

Issued 2/15/84