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VIRGINIA DEPARTMENT OF SOCIAL SERVICES CHANGE REPORT

10/24 VOLUME V, PART XXIV, PAGE 56

CHANGE REPORT

FORM NUMBER - 032-03-051

PURPOSE OF FORM - To provide a recipient household with a method of reporting changes in circumstances.

USE OF FORM - Recipient households may use the form to report changes in circumstances. Households must report changes to the agency when they occur but no later than 10 days after the month of the change.

NUMBER OF COPIES - One.

DISPOSITION OF FORM - The agency must provide the Change Report to all households at the time of initial application and reapplication and at recertification if the income limits listed on the form have changed or if the household needs another form. The agency must also provide the Change Report form whenever the household returns a completed one or reports a change in the household size.

INSTRUCTIONS FOR PREPARATION OF FORM – The BPS must complete information at the top of the form before providing the form to the household. The BPS must also highlight the household size and income limit that applies to the household when the form is provided.

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