CHANGE
REPORTED:
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 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 Monthly
allowable deductions/expenses Verification used; if collateral contact
was used, list the name and telephone number
CHANGE IN ADDRESS
New
address Household
composition *** Move-in
date Landlord’s
name and telephone number if renting Monthly
rent amount / mortgage payment SUD
/ Anticipated utility payments *** Verification
used; if collateral contact was used, list the name and telephone
number
***
not applicable for FS Semi-Annual Reporting
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
(cont.) |
Income Resource Purchase
and prepare (for FS) Verification
used; if collateral contact was used, list the name and telephone
number
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. |
