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DETAILS ON CHANGES THAT HAVE OCCURRED

CHANGE IN THE NUMBER OF PEOPLE IN YOUR HOUSEHOLD

HAS ANYONE MOVED IN? Name Date moved in Relationship to you Social Security Number Date of Birth Race (not required) Sex Marital Status U.S. Citizen Yes ( ) No ( ) If Alien, give alien number, date of entry Last school grade completed Currently in School? Yes ( ) No ( )

HAS ANYONE MOVED OUT? Name Date moved out Name Date moved out CHANGE IN YOUR ADDRESS New Address (Street, Apt. Number) City, State, ZIP CHANGE IN SHELTER EXPENSES THAT RESULT FROM THE MOVE (If you have not moved, you may report es in your changes in your expenses for your current home. Be sure to provide proof of the expenses.) Rent or Mortgage $ per Property Taxes $ per Homeowner’s Insurance $ per Electricity $ per Gas $ per Oil $ per Kerosene, Coal, wood, etc. List and give amount Water/Sewer $ per Garbage $ per Telephone (Basic Service Only) $ per Installation Fees $ per CHANGE IN LEGALLY OBLIGATED CHILD SUPPORT PAID TO ANOTHER HOUSEHOLD -Person paying support Person receiving support Amount legally obligated $ per Amount paid $ per CHANGE IN YOUR LIQUID RESOURCES SUCH AS CASH, BANK ACCOUNTS, BONDS, ETC. THAT REACH OR EXCEED $3,000 OR $4,500* (*$4,500 applies only if someone in your household is 60 years of age or older or who is permanently disabled.) Name

Account Type Balance RECEIPT OF LOTTERY OR GAMBLING WINNINGS OF $4,500 OR MORE Name Gross Amount Received Where Received When Received CHANGE IN THE NUMBER OF WORK HOURS IN A WEEK GOES UNDER 20 FOR MEMBERS WHO ARE BETWEEN THE AGES OF 18-54 IF THERE ARE NO CHILDREN IN THE HOME. Name Number of Work Hours CHANGE IN INCOME OF MORE THAN $125 (money from working or from sources such as Social Security, SSI, pensions, etc.) Name Income Type Amount CHANGE IN INCOME SOURCE - HAVE YOU STARTED OR STOPPED RECEIVING INCOME? Name Source Date Started/Stopped Number Of Hours If Started Working HAVE YOU CHANGED FROM FULL-TIME TO PART-TIME OR PART-TIME TO FULL-TIME? Name Employer Number Of Hours OTHER CHANGES

Person completing this form Date