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FOOD STAMP HANDBOOK Handbook FORMS AND INSTRUCTIONS 63-1230 (Cont.}

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

DFA 377.5 (12/83)

Form instructions (For the Eligibility Worker)

FOOD STAMP HOUSEHOLD CHANGE REPORT

Purpose:

The DFA 377.5 is completed by a nonmonthly reporting household and is used to report changes in household circumstances that occur within the certification period. The household completes only the section(s) pertaining to the changes} it is reporting. it is not mandatory that the household use this form to report a change as changes may also be reported by telephone or personal contact. This form is provided to the household at the time of initial certification, recertification, and also whenever the household submits a completed DFA 377.5 to the CWD. The CWD must pay the postage for the household to mail in the report. The Eligibility Worker uses the reported information to compute any change in the household's eligibility or benefits.

NOTE: Nonmonthly reporting PAFS households meet their food stamp reporting requirements by reporting any changes on the CA 7.

Preparation:

Enter the following information on the top of the front page of the report before providing it to the household:

— Head of household’s name and mailing address — Worker — Phone Number

Manual information Question Section Requested EW Action

County- 63-504.422 Verification must be obtained prior to the issu-

Use ance of any increase in benefits as a result of

Section the reported change. Document verification of income in the county-use section.

1A 63-300.5 Income Changes If the household's income changes by more

63-504.422(b) than $25 or the source of income changes, the

63-505.511 household completes this section and section

iC. The household’s total monthly income (before deductions) is used to compute the change. Be sure that all pay stubs or other income verification are provided,

CALIFORNIA-DSS-MANUAL-S Issue 649 Issued 2/15/84