CHANGE REPORTED |
QUESTIONS TO ASK / INFORMATION NEEDED |
CHANGE
IN EMPLOYMENT
(INCLUDING
SELF-EMPLOYMENT)
|
Did the household member
start or end a job?
If
the household member started a job, document the following
information: Employer’s/supervisor’s
name and telephone number Start
date of employment Expected
hours of work per month or work schedule Full-time
or part-time Hourly
pay rate Pay
period Verification
used; if collateral contact was used, list the name and telephone
number
If the household member
ended their job:
Employer’s/supervisor’s
name and telephone number Date
of job ending Reason
for job ending Date
and amount of last pay received including YTD gross Verification
used; if collateral contact was used, list the name and telephone
number
If the household member
changed employment status from full-time to part-time:
Effective
date of change Hours
of work and schedule Hourly
pay rate Full-time or part-time Verification used; if
collateral contact was used, list the name and telephone number
Change in self-employment
Effective
date of change Type
of self-employment Period
of self-employment Monthly
gross earnings Seasonal
or annual Income
and expenses allowed (50% versus actuals) Verification
used; if collateral contact was used, list the name and telephone
number
|
CHANGE IN ADDRESS
|
*** not applicable for
SNAP Semi-Annual Reporting
New
address Household
composition *** Date
of move Monthly
rent amount / mortgage payment/subsidized housing SUD
/ Anticipated utility payments *** Type
of verification ***
|
CHANGE IN HOUSEHOLD COMPOSITION
|
Name
of the person who moved in or out of the home Date
the person moved in or out Relationship
of the PI to the person Social
security number Date
of birth Income Resource Purchase
and prepare (for SNAP) Verification
used; if collateral contact was used, list the name and telephone
number Apply
appropriate program rules for other information needed. |
BANK ACCOUNT OR CASH
ON HAND EXCEEDS $2000
|
Name
of bank or institution Account
number Source
of money deposited in the bank or cash on hand Verification used; if
collateral contact was used, list the name and telephone number
|
GETTING
A VEHICLE
|
Make, model, year of vehicle Value of vehicle Amount owed How is this vehicle used?
(i.e., family/basic transportation, going to work, etc.) Verification used; if
collateral contact was used, list the name and telephone number
|
CHANGE IN SOURCE OF UNEARNED
INCOME OR CHANGE IN TOTAL UNEARNED INCOME OF MORE THAN $50
|
Source of income Amount of income Effective date of change How long is the change
anticipated to last Verification used; if
collateral contact was used, list the name and telephone number
|
CHANGE
IN THE AMOUNT OF THEIR LEGALLY OBLIGATED CHILD SUPPORT: |
|
CHANGE
IN MEDICAL INSURANCE COVERAGE |
Primary holder Insurance company’s name,
address and telephone number Effective date of coverage
for each person covered Name of household members
covered Extent of coverage (i.e.
medical, dental, vision, accidental only, etc.) Group and policy number Verification used; if
collateral contact was used, list the name and telephone number
|
OTHER
CHANGES
|
*
The client may report other changes that are not addressed above.
These may include a change in their work hours, change in current
shelter costs or the purchase of property. These
reported changes must be documented. The caseworker is responsible
for redetermining eligibility and benefit amount based on the
change reported. Inquire about any retirement resources or income.
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