Es 3114 Form Kansas PDF Details

Living in Kansas and navigating the process for food assistance can often feel like a daunting task. However, the ES-3114 Kansas Form, crafted by the Department for Children and Families (DCF), plays a vital role in simplifying this process. This particular form is an Interim Report Form designed for individuals currently receiving food assistance to report any major changes in their household that might affect their eligibility. Whether there's been a change in household composition, employment status, income from other sources, or even living arrangements, the ES-3114 form covers it all. The necessity of updating the DCF with accurate information cannot be overstated, as omitting to do so by the specified deadline could lead to the closure of one’s food assistance case. Moreover, this form stands as a testament to the commitment of Kansas’s Economic and Employment Services towards ensuring that assistance is accurately provided to those in need, emphasizing the importance of transparency and up-to-date information. It even includes reminders of the potential consequences of committing fraud, emphasizing the commitment to honesty in the pursuit of assistance. The instructions are clear - return the form by a given date, include information about changes in employment, other income, or living situations, and be aware that failure to do so could result in discontinuation of benefits. Dive into the specifics of this essential document to understand its significance and ensure the continuation of food assistance benefits without interruption.

QuestionAnswer
Form NameEs 3114 Form Kansas
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesks food assistance interim report form, ks interim report, kansas food assistance interim report, kansas es food assistance form

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STATE OF KANSAS

DEPARTMENT FOR CHILDREN AND FAMILIES

ECONOMIC & EMPLOYMENT SERVICES

ES-3114 10-14

 

FOOD ASSISTANCE INTERIM REPORT FORM

Name:

 

Case Number:

 

Address:

City, State, Zip:

We need the following information to determine if you are still eligible for food assistance. Please complete this form and return it to us by___________________________________________________.

If you do not complete and return this form your food assistance case will close

________________________.

Use extra paper if needed to answer all the questions.

This action is based on Kansas Economic and Employment Services Manual Sections 9122 and 9372.

If you have questions or need help completing the interim report form, contact your local DCF office or call 1-888-369-4777.

1.

Have any persons moved in or out of your home since you last reported? No

Yes

 

If yes, list the name and date of birth and mark whether they moved in or moved out of your home

 

below.

 

 

 

 

Name

Date of Birth

 

 

 

___________ _______________ (check one) Moved In

Moved Out

 

 

___________ _______________ (check one) Moved In

Moved Out

 

 

___________ _______________ (check one) Moved In

Moved Out

 

 

___________ _______________ (check one) Moved In

Moved Out

 

2.For all persons in your home who are working, answer the following questions:

a. Has anyone changed employers since last reported? No

Yes

If yes, enter name__________________ and complete the following. If no, go to item b below.

Name of Employer___________________________________Phone Number____________

Hours Worked Per Week_________________Hourly Rate or Salary____________________

Day of Week Paid______________ How Often Paid_________Date of First Pay__________

If anyone has changed employers, please provide the most recent 30 days of paystubs.

b. If anyone is still with the same employer, has there been a change in the wage rate, salary, or

full-time or part-time employment status since you last reported? No

Yes

If yes, enter name________________________________ and complete the following:

Hours Worked Per Week___________________ Hourly Rate or Salary__________________

Explain:____________________________________________________________________

If the income has changed, please provide the most recent 30 days of paystubs.

1

3.

Has anyone started a job since last reported? No

Yes

 

If yes, enter name______________________________________ and complete the following:

 

Name of Employer_________________________________Phone Number_________________

 

Hours Worked Per Week_________________Hourly Rate or Salary_______________________

 

Day of Week Paid______________ How Often Paid_________Date of First Pay_____________

 

If anyone has started a job, please provide the most recent 30 days of paystubs.

4.

Has anyone stopped a job since last reported? No

Yes

If yes, explain:_________________________________________________________________

5.For all persons in your home that are getting other income (child support, Social Security, SSI,

VA, Unemployment Benefits, etc.), has that income changed by more than $50? No Yes If yes, explain:_________________________________________________________________

6.Has the amount of cash on hand, stocks, bonds or money in a bank account or savings institution

reached or gone over $2,250? No

Yes

If yes, explain: _________________________________________________________________

7.Have you moved? No Yes

If yes, answer the following questions:

a.Your new address:___________________________________________________________

b.Date moved:________________________________________________________________

c.Landlord name, address and phone______________________________________________

__________________________________________________________________________

d.Rent/mortgage amount:_______________________________________________________

e.Property taxes not included in mortgage (if applicable)_______________________________

f.Homeowners insurance not included in mortgage (if applicable)________________________

g. Do you pay for heating or cooling at your new address? No Yes

8.For all persons in your home that have a legal obligation to pay child support, have there been

any changes in the legal obligation to pay child support (court ordered amount increased or decreased)? No Yes

If yes, explain:_________________________________________________________________

_____________________________________________________________________________

If yes, please provide proof of the change in your legal obligation to pay child support.

9.List any other information you would like DCF to know:_________________________________

_____________________________________________________________________________

_____________________________________________________________________________

10.Signature and Date:

I UNDERSTAND THE QUESTIONS ON THIS FORM, AND I CERTIFY, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN BY ME ON THIS FORM IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I also understand that any changes reported on this form may result in a reduction or termination of benefits. I also understand that if I am found guilty of fraud I may not get food assistance for one year for the first offense, two years for the second offense and permanently for the third offense. SIGNATURE___________________________________DATE___________________________

TELEPHONE NUMBER WHERE YOU CAN BE REACHED______________________________

2

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