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West Virginia Income Maintenance Manual Chapter 10

West Virginia Income Maintenance Manual Page 86 Chapter 10 The Case Maintenance Process

APPENDIX C: PUBLIC FORMS

Form Number Form Title DFA-SNAP-2 Reporting Changes

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES Supplemental Nutrition Assistance Program (SNAP) CHANGE REPORTING FORM If you wish to report changes for your SNAP benefits, you may use this form to do so. This will help make sure you get the correct benefits you are eligible to receive. If you receive SNAP benefits, you are not required to report changes except when the gross earned and unearned income of everyone who lives in your home exceeds the gross income limit for your assistance group’s size. In addition, if your household contains an Able-Bodied Adults Without Dependents (ABAWD), you may need to report additional changes. The gross income limit for your assistance group and the additional reporting requirements for ABAWD can be found on any recent notification letter or may be obtained by contacting the Customer Service Reporting Center. However, any changes that you choose to report will be acted on for all programs if required. If you are unsure of the reporting requirements for the benefits you receive, please contact the Customer Service Reporting Center at 1-877-716-1212 before reporting information. If you intentionally give FALSE INFORMATION or WITHHOLD INFORMATION, you will have to pay back your SNAP Benefits and may be disqualified from SNAP for 12 months, 24 months or permanently. In addition, you may be found guilty of FRAUD. Punishment upon conviction may be a fine up to $250,000 or a jail sentence of up to 20 years. Name (Please print):

Case Number:

SIGNATURE:

DATE:

1. Please check one of the following boxes:

The changes I am reporting are only for this month.

The changes I am reporting will be continuing.