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CHANGE REPORTED:
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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:
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Employer’s/supervisor’s name and telephone number
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Start date of employment
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Expected hours of work per month or work schedule
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Full-time or part-time
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Hourly pay rate
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Pay period
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Verification used; if collateral contact was used, list the name and telephone number
If the household member ended their job:
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Employer’s/supervisor’s name and telephone number
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Date of job ending
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Reason for job ending
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Date and amount of last pay received
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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:
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Effective date of change
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Hours of work and schedule
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Hourly pay rate
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Full-time or part-time
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Verification used; if collateral contact was used, list the name and telephone number
Change in self-employment
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Effective date of change
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Type of self-employment
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Period of self-employment
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Monthly gross earnings
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Monthly allowable deductions/expenses
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Verification used; if collateral contact was used, list the name and telephone number
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CHANGE IN ADDRESS
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New address
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Household composition ***
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Move-in date
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Landlord’s name and telephone number if renting
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Monthly rent amount / mortgage payment
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SUD / Anticipated utility payments ***
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Verification used; if collateral contact was used, list the name and telephone number
*** not applicable for FS Semi-Annual Reporting
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CHANGE IN HOUSEHOLD COMPOSITION
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Name of the person who moved in or out of the home
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Date the person moved in or out
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Relationship of the PI to the person
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Social security number
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Date of birth
(cont.)
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Income
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Resource
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Purchase and prepare (for FS)
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Verification used; if collateral contact was used, list the name and telephone number
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BANK ACCOUNT OR CASH ON HAND EXCEEDS $2000
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Name of bank or institution
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Account number
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Source of money deposited in the bank or cash on hand
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Verification used; if collateral contact was used, list the name and telephone number
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GETTING A VEHICLE
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Make, model, year of vehicle
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Value of vehicle
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Amount owed
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How is this vehicle used? (i.e., family/basic transportation, going to work, etc.)
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Verification used; if collateral contact was used, list the name and telephone number
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CHANGE IN SOURCE OF UNEARNED INCOME OR CHANGE IN TOTAL UNEARNED INCOME OF MORE THAN $50
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Source of income
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Amount of income
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Effective date of change
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How long is the change anticipated to last
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Verification used; if collateral contact was used, list the name and telephone number
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CHANGE IN THE AMOUNT OF THEIR LEGALLY OBLIGATED CHILD SUPPORT:
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CHANGE IN MEDICAL INSURANCE COVERAGE
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Primary holder
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Insurance company’s name, address and telephone number
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Effective date of coverage for each person covered
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Name of household members covered
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Extent of coverage (i.e. medical, dental, vision, accidental only, etc.)
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Group and policy number
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Verification used; if collateral contact was used, list the name and telephone number
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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.
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