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CASE NAME:___________________________________________ CASE NUMBER:____________________________________ DATE: ___________________________________
ADMINISTRATIVE REVIEW CONTACT DOCUMENTATION Household Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Income Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Other Changes: ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ TAX FILING /DEPENDENT STATUS: In the first column write the name of each person in the HH and put an “X” for each person’s tax filing status for the current calendar year and/or indicate tax dependent and claiming status.
Name of HH Member Not a tax filer Filing Married Filing Jointly Married Filing Separately Filing Taxes Single Tax Dependent of someone in HH (List Person) Tax Dependent of someone outside the HH (List Person/Relationship)