Dss Form 16181 – Fill Out and Use This PDF

South Carolina Department of Social Services

CHANGE REPORT FORM

FOR THE ELDERLY SIMPLIFIED APPLICATION PROJECT (ESAP)

This is a change report form. Please keep this form until you have one of the changes below. You have been approved for food stamps through the Elderly Simplified Application Program (ESAP). As a food stamp recipient, there are certain changes you must report.

You must report within 10 days from the date you learn about the change:

1.If you move and have any new shelter and utility costs resulting from the move. New Address:

New Shelter Costs – Rent:						Mortgage:
Property Taxes:						Homeowner’s Insurance:
Do you pay for heating or cooling costs?				Yes	No
If no, what utilities do you pay?

2.If someone moves in or out of your household. Tell us who moved into your household:

Name:				Relationship to You:
Social Security Number:				Date of Birth:
Do you purchase and prepare your meals together?					Yes	No
Tell us who moved out of your household:

3.If you pay child support and the legal obligation of the amount of this child support changes. What is the new amount of child support you pay?

You must report any change in the source or in the amount of unearned income received from a public source (for example, social security, SSI, Veterans benefits, unemployment compensation) if the amount changes by more than $50 a month. This must be reported no later than 10 days after you receive the changed amount.

Source of Income:			Who receives this?
Old Amount:			New Amount:
Source of Income:			Who receives this?
Old Amount:			New Amount:

You must report any change in the source or in the amount of unearned income received from a private source (for example, retirement/pensions, child support, cash from friends/relatives) if the amount changes by more than $100 a month. This must be reported no later than 10 days after your receive the changed amount.

Source of Income:			Who receives this?
Old Amount:			New Amount:
Source of Income:			Who receives this?
Old Amount:			New Amount:

You must report if you go to work no later than 10 days from the date you receive your first check.

Name of Employer:

Date of First Paycheck:

Please keep this form until you have one of the above changes. Do not send this form in unless you have changes! To report changes, send this form to SCDSS, ESAP, P.O. Box 1520, Columbia, SC 29202-1520 or take this form to your local DSS office and ask them to send this to ESAP for you. You may also report changes by calling 1-800-616-1309.

DSS Form 16181 (JUN 06)