Upload
vuxuyen
View
215
Download
2
Embed Size (px)
Citation preview
RICHARD WHITLEY, MSDirector
BRIAN SANDOVALGovernor
STATE OF NEVADADEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICESSTEVE H. FISHER
Administrator
2584 - EG (216.0.0)Page 1 of 2
CHANGE REPORT FORMTHE LAW SAYS YOU MUST REPORT CHANGES TO US WITHIN 10 DAYS AFTER THE CHANGE HAPPENS IF YOU ARE
RECEIVING SNAP BENEFITS AND BY THE 5TH OF THE FOLLOWING MONTH FOR TANF AND/OR MEDICAL ASSISTANCE.Fill in the spaces below. (You can write an explanation on a separate sheet of paper.) You can mail or bring this report into the office.
PLEASE PROVIDE PROOF OF THE CHANGES.NAME SOCIAL SECURITY NO.
ADDRESS APT # HOME PHONE CELL PHONE
E-MAILCITY/ZIP CODE
Is this a new address? YES NOMAILING ADDRESS (If different)
PEOPLE CHANGES: Did someone move in move out or have a baby? Please provide details below.
NAME DATE MOVEDIN OR OUT
DATE OFBIRTH
SOCIALSECURITY NO.
RELATIONSHIP
Is the member moving in a tax filer? YES NO
Is the member moving in a tax dependent? YES NOIf yes, who claims this member as a tax dependent?
INCOME AND JOB CHANGES
Did someone get a new job? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per month
Medical insurance available? YES NO Effective Date
Did someone end a job? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per month
Medical insurance available? YES NO Effective Date
Did someone change work hours or pay? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per mont
Medical insurance available? YES NO Effective Date
2584 - EG (216.0.0)Page 2 of 2
OTHER INCOME CHANGES (Unemployment benefits, Social Security benefits, SSI, disability, child support, etc.)Explain type of income and change:
How much is received each month? $ Who receives this income?
EXPENSE CHANGES
New rent/mortgage payment? $ Do you pay utility bills? YES NOChild Care Expenses? $
Medical expenses for the elderly (60+) or disabled?
Does anyone pay part of these expenses? Explain:
New child support you are ordered to pay? $
RESOURCE CHANGES
You must report any changes in resources (checking/savings accounts, bonds, home/land, boat, life insurance, vehicles, etc.).Include specific information about the opening, closing, purchasing, selling of, or changes to resources. Explain:
OTHER CHANGES NOT LISTED ABOVE
i.e. Pregnancy
PLEASE READ AND SIGN: “I understand the penalty for hiding information or giving false information. I understand that I must repay the value ofany benefits I get because I did not report changes or failed to report changes timely. I understand I may be disqualified from getting benefits. I canbe fined or prosecuted or both if I do not tell the truth. I agree to provide proof of any changes if asked to do so. My answers on this form are true,correct and complete to the best of my knowledge.”
/ /Client Signature Print Name Date Telephone Number
PROVIDE PROOF OF CHANGESIF WE CHANGE YOUR BENEFITS WE WILL SEND YOU A NOTICE.
��
�� �� �� ��
��
��
��
��
��
��
�� ��
�� ��
EMAN-3XOB
S
SSERDDAEMOH-4XOB
elp,noitacifitnedifosmrofesehtruceSlaicoSro,dracDI,esneciloyetirwesaelP
ruoYYo
IGERRETOVATTASTSFOYRRYATTAERCES
.8xoBrofsnoitcurtsniehteesesaeoduoyfI.8xoBnidecnereferdracytiehtnosraeppatisayltcaxeemanru
sserddateertsehtsisserddaemoh
CILPPANOITARTSIADAVVAENFOETAAT
.KARABRABETAATTTA
foynaevahtonos’revirdadaveN
ehtotdengissa
SISSA-41XOB
ROFSENILDAED
retsigerotnosrep
op—liaMyB�
NOITA
EKSVAAVGEC.
SIHTFONOITELPMOCEHTNIGNIT
NOITAATCILPPAGNITTIMBUS
F.41xoBetelpmoctsumuoy,etovotr
ofebsyad13,yadrutaSybdekramtso
MROFS.YY.NOLEFASIOSODOTERULIAFFAagnitsissaerauoyfI
.noitcelEnaer
.oNnoitacilppA
SSERDDAEMOH4XOB
IUQERNOITAATCIFITNEDI-8XOB
acxoB.O.PP.A.dedivorpebtsumeda,sserddateertsadengissayllautcauoyhcihwtanoitacolruoYYo
OITAATRTSIGERYTRAPPA-11XOB
rofsihtdenruterdnadetelpmocaelp,noitacifitnedifosmrofeerhteslaicosruoyfostigid4tsalehtDIVNroesnecils’revirdVNruoy
k/
STNEMERI
.sserddaemohasadetsilebtonnuoyhcihwtanoitacolehtfonoitpircsehtnoitacolataediseruoyfI.edisersserddateertsehtsisserddaemoh
N
.martsigeR/krelCytnuoCruoytcatnocesaahtonoduoyfI.)NSS(rebmunytirucey,rehtieevahtonoduoyfI.rebmunDiuqerwaletatsdnalaredeF
trapdeifilauqafoeciohcruoykraM
k/
ediseryllautcauneebtonsahtaehtotdengissa
evahuoyretfaraesehtfoynaevaedivorptsumuoedivorpotuoyer
”nasitrapnoN“,yt
ECITON
/laicepSroF�
lEnaerofebtAnosrePnI�
yb—enilnO�
tanosrePnI�
etoveresaelP.etovotehtreviledotsliafnosreprehtonaotnirartsigeR/krelCerauoYYo
k/k/
tnuoCruoytcatnoc—snoitcelEllaceR/repni,snoitcelElapicinuMrof(noitcel—eciffOs’rartsigeRros’krelCytnuoCt.noitcelEnaerofebsyad12,yadseuTaerofebsyad13,yadrutaSyb—VMDt
morftpiecerroypocetacilpudehtniateigeR/krelCytnuoCehtotnoitacilppaeartsigeR/krelCytnuoCehtotnruterotgotesoohcuoyfI.liamybronosrepnotnoitacilpparuoynruterotdegru
.rartsigeRrokrelCyt.)s’krelCytiCtanosrsyad12,yadseuTyb—
.noitcelEna
otretsigerotnoitacilpparuoymderetsigerebtonlliwuoy,rartsnosrepehtdna,flahebruoynornoitacilppadetelpmocruoyevigytnuoCehtotetovotretsiger
1
P—KNIKCALABESU
EyramirPehtroftollabnasitraptilopronimahtiwretsigeruoyfI”,rehtO“kramuoyfI”.rehtO“ro
htfoneziticauoyerAosraey81ebuoylliWni”on“dekcehcuoyfI
YLLYRAELCTNIRPESAELP
.noitceliwuoy,nasitrapnonasaroytraplacitetsilnunafoemanehttnirpyamuoy
� OTXOBSIHTKCEHC
?aciremAfosetatSdetinUeaDnoitcelEerofebronorevoroegafonoitseuqesehtforehtieotesnopsern
2EDULCNIDNAVIG:GNINRAWWA
-nonaeviecerll.ytraplacitilopde
BNIDETSERETNI
.etov
eciffOs’rartsigeR
ABELPMASAEVIECERO
� seYYe �?ya
oN� seYYe �
tonod,soN
T
UFOYTLLTANEPLIVICASENOITAATMROFNIESLAFFAGNIV
?REKROWLLOPAGNIEB.esreveReeS.
nocesaelP
EPYTREGRALNITOLLA
lpmocdnaylppatahtsexobkcehC
� noitartsigeRweN � P
� egnahCemaN � A
.000,02$OTPYNOLEFASIN
rokrelCytnuoClacolruoytcatn
41-3smetietel
egnahCnoitailiffAytraP
egnahCsserddA
8 oNesneciLs’revirDVN
4 sserddAteertSemoH
3 )ylnO(emaNtsaL
.mrofsihtetelpmocy
5 dfI—sserddAgniliaM
x/
NSSfo4tsaL/.oNdraCDIVN/.
nIeeS.sserddAssenisuB/xoB.O.PP.oN(
O(emaNtsriF
qp
liaMroxoB.O.PP.(.evobamorftnereffi
9 ).tpO(.oNenohpeleTTe
ytiC#.tpA).snoitcurtsn
)ylnO
6 etaDhtriB)sserddAecivreS
0 tpO(sserddAliam-E1
etatS
)ylnO(emaNelddiM
� egnahCemaN � A
7 alP)RY/D/M(e
).t
edoCpiZ
VIIIIII.rS.rJ
egnahCsserddA
)yrtnuoCroetatS(htriBfoeca
1 C—noitartsigeRytraP1
� ytraPcitarcomeD
� mAtnednepednI
� ytraPnairatrebiL
� on(nasitrapnoN
� ytraPnacilbupeR
� rW–ytraPrehtO
2xoBenOylnOkceh
y
ytraPnacire
y
)noitailiffaytrap
y
1
woleBnIetir
AFOERUTAATNGIS}
rrocdnaeurtsigniogerofehttahtdluowtahtsthgirlivicfossolrehtoymsaecalprehtoonmialcIdna•noitceletxenehterofebtcnicerpdediserylsuounitnocevahlliwI•tic.S.UamaI•mriffaroraewsI“
})DERIUQER(TNACCAILPPA
”.tceredI.etovotemroflufwalnutiekamdugnirobaltonmaI•ecnediserlagelmsinierehdetsilsserddatneserpehTnuocymnisyad03tsaeltaadaveNnibdlosraey81tsaeltaeblliwI•nezit
//
})DERIUQER(ETAATD}
yrujrrjepfoytlaneprednueralceronoitcivnocynolefynarednuecnediserfoecalplagelelosymymnisyad01tsaeltadnaytnnoitceletxenehtfoetadehty
________________________________________
A
____________________
4
VVA
emaN
oy,ycneganoitartsigeraerauoyfI!tnatropmI1
3 ediserdnaemanruoYYo1
____________________________________________
O
______________________
ESUYCNEGAGNITAATDILA
sserddAgniliaM
uoYYo.gniwollofehtetelpmocTSUMuoetovotretsigerotnosrepagnitsissa
gertsalerewuoyerehwsserddaecn
TNIETIRWTONOD.YY.LLYNO
tatS/ytiC
odoteruliaF.deriuqersierutangisruopparartsigerdleifatonerauoydna
A,teertS,desUemaN(.etovotderetsi
k/
WOOWLEBAERADEDAHSEH
edoCpiZ/et
.ynolefasiosarorartsigeR/krelCytnuoCaybdetni
emroFfoedoCpiZ&etatS,ytiC,#.tpA
____________________
.
)YYYY/DD/MM(_____/____/____
W
erutangiS
retovafoeeyolpmena
)ecnediseRre
T
P
A
MATTASETAATD
VVA
AATCILPPASIHTRNOSREPFOEMAN
tereHhcateDt
N
R
O
EHTO
LIAM
GERDLEIF
YCNEGA
ESUYCNEGAGNITAATDILA
OITGNINIATTAER
ofnItcatnoCTCELE
e
R
T
T
CNICERP
EVITCANI
DELLECNAC
ARTSIG
NIETIRWTONOD.YY.LLYNO
tereHhcateDt
nohpeleTTe,sserddA,noitamroCNEGAROLAICIFFONOI
R
:
WOOWLEBAERADEDAHSEH
YBDEVIECER
ONNOITAATCILPPA
esaeleP((PILPPARETOOTV
xaF,eY
)
..W
O
tt)piipeceRniinattaeRTPIECERNOITAATC
tereHhcateDt
T
veRReOPSN()5102.7desiveR(
ERNOSREPFOEMANTNIRP
GNINIATTAERNOSREPROLAICIFFOGAFOEMANROPMATTASYCNEGA(
M
)51-9.
ROFGNINIATTA
)NOITAATCILPPAGNOITCELE,TNEG
ONNOITAATCILPPA
EytnuoCruoynihtiwliamehtnidraCaeviecertonoduoyfI
.
L201)O(
O
.tnemtrapeDnoitceltisivrollacesaelp,syad01
noitiarrattrsiisgeRretoVVoaddaavvaeNa
H
H
H