Form Dss Ea 310 – Fill Out and Use This PDF

Case #: ___________________ Section: __1__

DSS-EA-310 05/2017

Medical Assistance/TANF Change Report Form

_____________________________________________
Your Name	Benefits Specialist
_____________________________________________
Address	Address -
_____________________________________________
City, State, Zip Code	City, State, Zip Code –
____________________________________________
Phone Number	Phone Number –

Changes must be reported to your Department of Social Services Benefits Specialist as soon as you become aware of them, but no later than 10 days from the date of the change. You can report changes by coming into your local Department of Social Services Office, calling your Benefits Specialist or you can use this form to report the changes.

CHECK THE SECTIONS THAT HAVE CHANGED

For Medical Assistance and/or Temporary Assistance for Needy Families (TANF) Programs:

Someone moved into your home (complete section below)

Name of Person			Indicate if Requesting Medicaid Assistance and/or
			Temporary Assistance for Needy Families (TANF)
________________________________________________			Medical Assistance? YES		NO
First	Middle Initial	Last
			TANF? YES	NO
________________________________________________
DOB	Gender	SSN
Does this person plan to file a federal income tax return next year? YES				NO
If yes, please answer questions A - C
A.	Will this person file jointly with a spouse? YES		NO
	If yes, name of the spouse _____________________________________________________________________
B.	Will this person claim any dependents on your tax return? YES			NO
	If yes, list name(s) of dependents ________________________________________________________________
C.	Will this person be claimed as a dependent on someone’s tax return? YES				NO
	If yes, name of tax filer ________________________________ Relationship to tax filer _____________________

Someone moved out of your home (list person below):

Name of PersonDate Left

_________________________________________________________________________________________________

First Middle Initial Last

Employment income changed. Check reason(s) below:

Changed jobs

Stopped working

Started working fewer hours

Other: Describe change_______________________________________________________________________________________________

Provide employer information below:

Employer Name, Address and Phone Number	Wages/Tips (before taxes)			Average hours worked each WEEK
	$___________________________			__________________________
	Weekly	Twice a month
	Monthly	Every 2 Weeks	Yearly
		1

If self-employed, describe type of work and the change in income below:

Other income changed. Complete all that apply

Source of Income	Amount	How often received?	Source of Income	Amount	How often received?
Unemployment			Alimony Received
Pensions			Net Farming/fishing
Social Security			Net rental/royalty
Retirement			Other income type
Accounts

Someone in the household is pregnant. If checked, complete questions below:

Name of person that is pregnant: ______________________ Due Date _______ Number of babies ________

Someone gave birth to a child. If checked, complete questions below:

Date of birth: ______________ Name of newborn: _______________________________ Gender: ____________

For Medical Assistance Only:

Health insurance started, stopped, or company changed?

List the policy # ___________________________ Co. Name/address: _____________________________

Describe the change: ______________________________________________________________________

For TANF Only:

CHECK THE SECTION(S) THAT HAVE CHANGED, EXPLAIN & ATTACH PROOF:

Bank accounts/resources changed. Describe new accounts, increased amounts in existing accounts,etc.

___________________________________________________________________________________

Bought, sold, traded, or gave away vehicles (cars, trucks, boats, etc). Describe the change:

_____________________________________________________________________________________

The amount you pay for child support payments started, stopped, or changed. Describe who the payment is for, who it is paid to, and the change in payment:

_____________________________________________________________________________________

School attendance changed. Provide name, change that occurred, and date of occurrence:

____________________________________________________________________________________

I understand that the information on this form is subject to verification by Federal, State and local officials to determine that such information on this form is correct and complete. If any information is found to be incorrect, benefits may be reduced or terminated and I may be responsible for paying the benefits back. I declare and affirm under penalties of perjury that this report form has been examined by me and to the best of my knowledge and belief is in all things true and correct. I understand I may be subject to criminal prosecution for knowingly providing incorrect information.

________________________________________________________	___________
Signature	Date

Additional Comments: _____________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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