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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES CHANGE REPORT CASE NAME CASE NUMBER WORKER NAME LOCALITY AGENCY TELEPHONE NUMBER CERTIFICATION PERIOD YOUR HOUSEHOLD SIZE You must report changes that occur in your household to ensure that your Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) benefit amount is correct. You may use this form to report changes listed below for your SNAP or TANF case. You may also report changes online at https://commonhelp.virginia.gov/access/. Report changes within 10 days from when they occur but, no later than the 10th day of the next month. If you do not report changes, you may have to repay benefits you receive incorrectly, be fined, or prosecuted. Please note changes on the next page. Please provide proof if there are changes. • If you receive TANF, tell us if: • Your address changes; • A child, including a newborn, or the father, or the mother of a child, enters or leaves your home; • There are changes that may affect your participation in VIEW, such as changes in income, employment, education, training, transportation, and childcare; or • All the income for your household before taxes goes over the 130% Gross Income Limit listed in Chart A below.

Your case has been certified effective - based on a household size of .

• If you receive SNAP as part of the Elderly Simplified Application Project (ESAP) and your certification period is 36 months (three years), tell us if: • There is a change in the number of people in your household; • You have lottery or gambling winnings of $4,500* or more; or • You or any member of your household starts getting income from working.

• If you receive SNAP and your certification period is five (5) months or longer, tell us if: • All the income for your household before taxes goes over the limits in Chart B below unless the note for Chart A applies. • The number of work hours goes under 20 per week for persons who are between the ages of 18-54 if there are no children in the home. • You have lottery or gambling winnings of $4,500* or more.

• If you receive SNAP and your certification period is for one (1) month to four (4) months, tell us if: • There is a change in the number of people in your household; • Your address changes, including shelter expenses that change resulting from the move; • The obligation to pay child support changes or the amount paid to someone outside the household changes; • Your liquid resources, such as bank accounts, cash, bonds, etc. are $3,000 or $4,500* or more; • You have lottery or gambling winnings of $4,500* or more; • The number of work hours goes under 20 per week for persons who are between the ages of 18-54 if there are no children in the home; or • There are changes in income: • There are income changes of more than $125 except, you do not have to tell us if your TANF income changes if your TANF case is in Virginia; • The source of your income changes, including if you start or stop a job: or • Your job switches from full-time to part-time or part-time to full-time.

*Amounts are valid through 9/30/2026. Add together the gross income for all the people in your household. New income total $___________

Note: Chart A applies to SNAP households that have a member who cannot get SNAP benefits because of a felony conviction, a conviction for a SNAP intentional program violation, or because of an employment and training requirement. Please contact me at the number above if you are not sure which chart applies to you or if you need help completing this form.

This institution is an equal opportunity provider 032-03-0051-44-eng (09/2025) Chart 1 (Gross Income Limit 200%) Chart 2 (Gross Income Limit 130%) HH Size

Monthly

Weekly Every 2 Weeks Twice a Month HH Size

Monthly

Weekly Every 2 Weeks Twice a Month 1 $2,608 $ 606.51 $1,213.02 $1,304.00 1 $1,696 $ 394.41 $ 788.83 $ 848.00 2 3,525 819.76 1,639.53 1,762.50 2 2,292 533.02 1,066.04 1,146.00 3 4,441 1,032.79 2,065.58 2,220.50 3 2,888 671.62 1,343.25 1,444.00 4 5,358 1,246.04 2,492.09 2.679.00 4 3,483 810.00 1,620.00 1,741.50 5 6,275 1,459.30 2,918.60 3,137.50 5 4,079 948.60 1,897.20 2,039.50 6 7,191 1,672.32 3,344.65 3,595.50 6 4,675 1,087.20 2,174.41 2,337.50 7 8,108 1,885.58 3,771.16 4,054.00 7 5,271 1,225.81 2,451.62 2,635.50 8 9,025 2,098.83 4,197.67 4,512.50 8 5,867 1,364.41 2.728.83 2,933.50 Additional members

+$916.00

+$213.02

+$426.04

+$458.00 Additional members +$596.00 +$138.60 +$277.20 +$298.00