CHANGE REPORT FORM - Nevada · PDF fileIf yes, who claims this member as a tax dependent? ......
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RICHARD WHITLEY, MS Director BRIAN SANDOVAL Governor STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF WELFARE AND SUPPORTIVE SERVICES STEVE H. FISHER Administrator 2584 - EG (216.0.0) Page 1 of 2 CHANGE REPORT FORM THE 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-MAIL CITY/ZIP CODE Is this a new address? YES NO MAILING ADDRESS (If different) PEOPLE CHANGES: Did someone move in move out or have a baby? Please provide details below. NAME DATE MOVED IN OR OUT DATE OF BIRTH SOCIAL SECURITY NO. RELATIONSHIP Is the member moving in a tax filer? YES NO Is the member moving in a tax dependent? YES NO If 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
Transcript of CHANGE REPORT FORM - Nevada · PDF fileIf yes, who claims this member as a tax dependent? ......
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.
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