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FOOD STAMP HANDBOOK 8121230 (Cont) FORMS AND INSTRUCTIONS ~Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 377.5 (12/83)

® ADDRESS AND SHELTER COST CHANGES A Do you have a new maviing address or phone umber of do you plan to move? tf YES, complete @)c 4 Yes 8 Did you move? if YES, comptete(B)C and{ g)0. YES

G._Enter your new address and_or phone number below and enter the date of the change here:

Hame Addrass (Number, Stréet Name, Ava. Blvd. Eicy Apt.No Cnty State Zip Code Mailing Acaress (if different than home address) Prone No City Blais Zip Code 8. Did your housing or utility costs change when you moved? If YES, complete 1, 2 and 3 below: C] YES ° 1. Enter the amount of each housing cost you have and attach bills , Property Taxes or insurance: & for each cost, —mmememfiy Alert or Mortgage: $ (Hf not in mortgage} 7 . Utility Amount Utitity Amount 2. if you claim actual utility costs, enter the amount of each utility Gas or Fuai 8 Garbage or Trash | 6 cos! you have and attach bills for each cost, > ‘ Electricity & Water 8 Hf you claim the standard utility allowance, attach bills for [Telephone s Sewage 8 gas, electricity or other heating fuel. Unit Otner tspecity) instsllation § 8 3. Did anyone not part of your food stamp household help you pay any of your housing or utility costs? If YES, completeda,bandebelow. Lud YES a. Enter the total housing costs paid . Give the name of each person who. paid any of the by the food stamp household: § casts, and if they paid housing and/or utility costs,

6. Enter the total utility costs paid by the food stamp household: § cern re (8) DEPENDENT CARE EXPENSE CHANGES

Did you begin paying or has there been a change in the amount paid for the care of a child or disabled adult so that someone in the home Oo could go to work, training or foak far a job? YES

if YES, complete section below and attach a receipt.

Who Received Cara? Cost of Care Who Recsived Cara? Cost af Care Who Receivad Care? Cost of Cate Who Received Care?, Cost of Care a te 2. 2. 4. (7) DISQUALIFIED INDIVIDUALS, INELIGIBLE ALIENS Did any person living in your home who is an ineligible alien or who has been disqualified from the food Stamp Program have any of cy the changes in questions(}) through (6)? Yes YES, give the name of the person and the date af the change, and explain the change baiow: (@) OTHER CHANGES Do you have any other changes to report? if YES, explain below, D ves @) TEMPORARY CHANGES De you expact any of the changes reported on this form ta be temporary? tf YES, expiain below, CD ves

CERTIFICATION ¢ | undarstand that failing to report information or intentional misreprasentation of facts can result in fega! prosecution with penalties of fines up to $10,000 and imprisonment up to 5 years, ax well as permanent disqualification from the Food Stamp Program,

* f understand that | have only 10 days to notify my worker of changes in my household circumstances.

© f understand that the infarmation! have brovided will be verified by laced, state and federal pesonnnel

* f understand that iff tail to report 6 change and because of this | receive food Stamps | am nat entitled to, | will have to repay these benetsts. © f understand that | have the night to request 8 state hearing on any action by the County Waltars Department

& {declare that the information contained in this feport is true and correct.

ighaturé (Household Member or Authorized Representative Date Signature (Witness, # You Signed with an X} Date COUNTY USE SECTION E.W. initisis - Date

CALIFORNIA-DSS-MANUAL-SS Issue 648 Issued 215/84

PRAARIIAL te wres pin ag ams tlk in