Interim Change Report Form – Fill Out and Use This PDF

Interim Change Report Form is a document that describes changes made to an operational system. It should be used by the System Owner and the Approving Authority.

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Interim Change Report Form PDF Details

If you're responsible for completing an interim change report, you'll want to familiarize yourself with the form. The Interim Change Report Form is a required document for all changes made to an IT system. By completing and submitting this form, you'll help ensure that all changes are tracked and authorized in a timely manner. In this blog post, we'll provide an overview of the Interim Change Report Form and offer some tips on how to complete it efficiently.

We have compiled some statistical information about the interim change report form. It is really worth spending some time to read this before you begin filling in your document.

Question	Answer
Form Name	Interim Change Report Form
Form Length	4 pages
Fillable?	Yes
Fillable fields	143
Avg. time to fill out	29 min 36 sec
Other names	snap oregon change, dhs interim change report, interim change report snap, snap oregon form

12

Form Preview Example

Program: Branch: Case number:

Case name:

Worker ID:

Interim Change Report For

Supplemental Nutrition Assistance Program (SNAP)

To prevent a possible delay in receiving your benefits, please return this form between the 1st and 10th day of _________________________________.

If this form is not received by the last day of

_____________________ your benefits may stop.

To continue your benefits

•You must turn in this form to get benefits.

•Answer the questions for yourself and all persons living with you for _________________________________ .

•Attach a sheet of paper if you need more room.

•Attach proof of what you report.

•If you need help with this form, call the number at the top. You may call collect, if necessary.

Your benefits may get delayed if:

•You return this form after the 10th of the month, or

•It is incomplete.

This is not an application

How to use this form

This form is needed to show that you are still eligible for food benefits. Answer all questions about all who live with you. Give all household income from all sources. This includes earned and unearned income for all household members.

Our discrimination policy

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age,

race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.

You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at:

Governor’s Advocacy Office

500 Summer Street NE, E17, Salem, OR 97301 Email: DHS.info@state.or.us

1SNAP clients are protected against political belief discrimination.

2Sexual orientation is protected by the State of Oregon, but not federal laws.

Answer all questions. Be sure to sign and date on the back.

DHS 0852 (10/18) Page 1, Can use prior version

“Equal opportunity is the law!”

The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) are equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals with disabilities.

To file a complaint with USDA, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 or call 202-720-5964 (voice and TDD).

By signing this form, I understand and agree that:

I must return this information to get benefits.

I can talk to my worker or a person in charge if I have questions about this form.

I register for the Oregon Food Stamp Employment Transition (OFSET) program all people in my household who want food benefits.

My answers on this form will affect my benefits. This information may cause my benefits to go up, down or stop. I will get a notice explaining how my answers on this form will affect my benefits and how to ask for a hearing.

If I quit a job without a good reason, I may lose food benefits for myself.

There are penalties in the SNAP program for doing any of the following:

If you do the following...		You will lose food benefits...

•	Hide information or make false statements;	•	12 months for the first offense;
•	Use Electronic Benefit Transfer (EBT) cards that	•	24 months for the second offense;
	belong to someone else;	•	Permanently for the third offense.

•Use food benefits to buy alcohol or tobacco;

•Trade or sell benefits or EBT cards;

•Dump containers only for the cash redemption value;

•Resell food bought with food benefits for cash.

•	Trade food benefits for controlled substances	•	24 months for the first offense;
	such as drugs.	•	Permanently for the second offense.
•	Trade food benefits for firearms, ammunition	•	Permanently.
	or explosives.
•	Trade, buy or sell food benefits of $500 or more.	•	Permanently.

•	Give false information about who you are or	•	10 years for each offense.
	where you live so you can get extra food benefits.

You can also be fined up to $250,000 or put in prison for up to 20 years, or both, for doing these things. You may also be charged under other Federal laws.

If you knowingly do the following...		You may be...

• Use EBT cards which are not yours;		•	Guilty of a felony or misdemeanor;
•	Transfer your EBT cards to other people;	•	Fined;
•	Acquire or possess EBT cards which are not yours.	•	Put in prison;
		•	Ineligible for food benefits for a period of time.

DHS 0852 (10/18) Page 2, Can use prior version

Program: Branch:

Case name:

Worker ID:

Case number:

If you are not registered to vote where you live now, would you like to apply to register

to vote today? c Yes c No Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency.

(1) Answer the questions for (report month):

Home address:

Mailing address:

City:

City:

State:

State:

ZIP code:

ZIP code:

Phone number:

Message number:

Do you pay for housing?	c Yes			c No (If yes, complete below.)				c Rent c Mortgage

Amount you pay monthly?			Homeowners insurance, if separate:					Property tax, if separate:
$ ____________			$ ____________ per year					$ ____________ per year
How is your home heated?	c Wood			c Oil	c Electric	c Gas		c Other: ___________________
Is the heating expense included in the rent? c Yes					c No

Check all utilities that you pay.			c Electricity		c Phone	c Water/sewer			c Wood
			c Natural gas		c Propane	c Garbage			c Oil

(2)Who lives at this address with you? (List each person living in your home.)

		Relationship	Sex	Date of	Wants SNAP		Purchase and
	Name (last, first, middle)	Relationship	Sex	Date of	Wants SNAP		prepare meals
	Name (last, first, middle)	to you	(circle one)	birth	(circle one)		with you
		to you	(circle one)	birth	(circle one)		with you
							(circle one)

		Self	M F		Y	N	Y	N

			M F		Y	N	Y	N

			M F		Y	N	Y	N

			M F		Y	N	Y	N

			M F		Y	N	Y	N

			M F		Y	N	Y	N

			M F		Y	N	Y	N

If there are others living in your home, add to a separate sheet of paper.

(3) Does anyone get money from any other source? c Yes c No (if yes, complete below, attach proof.)

Some examples are:	• Social Security		• Unemployment Compensation			• Veterans benefits
	• Child support		• Workers’ Compensation			• Loans/gifts
Name of person who got	Source of	How often		Amount of	Amount	Will this
other money	other money		paid	each payment	this month	income continue

				$	$	c Yes	c No*
				$	$	c Yes	c No*
				$	$	c Yes	c No*

* If income will change, give the new amount. What is the reason for the change and when it will change?

Turn over and answer all questions. Be sure to sign and date on the back.

DHS 0852 (10/18) Page 3, Can use prior version

	(4) Does anyone work? c Yes	c No (If yes, complete below.)
	List each job for each person who works. Attach proof of the income received in the
	report month. (Report month is listed at top of page 3.)

	If self-employed, check here c	Job #1	Job #2	Job #3

	Person working:
	Employer’s name and phone number:

	Job title:
	Hourly pay:	$	$	$
	If you are not paid by the hour, explain your	income here:
	Hours (per week):
	How often paid (weekly, monthly):
	Pay dates:
	Tips per week:
	Draws, overtime pay, bonuses or	$	$	$
	commissions:	$	$	$
	commissions:
	Will this income continue?	c Yes c No*	c Yes c No*	c Yes c No*

	*If income will change, give the reason for	the change here:

	New amount:	$	$	$
	Date of the change:

(5) Does anyone in your household work as a volunteer?

Name of volunteer:

Hours per week:

(6)Paying child support: If anyone living with you is court-ordered to pay child support, has the

court-order changed? c Yes c No

If yes, amount per month $_________________

Read and sign: The information I give on this form is true and complete. I have read all four pages of this form and understand it. I agree to the conditions on page 2.

Signature of person completing this form:

Phone:

Date:

Original: Case record

DHS 0852 (10/18) Page 4, Can use prior version

How to Edit Interim Change Report Form Online for Free

We have used the hard work of the best software engineers to build the PDF editor you are going to benefit from. Our software allows you to fill out the report changes interim file effortlessly and don’t waste valuable time. All you should do is comply with these particular straightforward recommendations.

Step 1: Select the button "Get Form Here".

Step 2: Now you can enhance the report changes interim. You need to use the multifunctional toolbar to add, eliminate, and change the content of the file.

These areas are in the PDF form you'll be filling out.

example of blanks in snap oregon form

Write the details in Program, Branch, Worker, ID, Case, number Case, name ZIP, code State, City, Phone, number Mailing, address City, State, ZIP, code Message, number Do, you, pay, for, housing, c, Yes c, No If, yes, complete, below and c, Rent, c, Mortgage

step 2 to entering details in snap oregon form

Type in the necessary information since you are within the to, you circle, one birth, circle, one withyoucircle, one Self, Some, examples, are Name, of, person, who, got Amount, of How, often Amount, this, month other, money paid, each, payment and income, continue, c, Yes, cNoc, Yes, cNoc, Yes, c, No segment.

step 3 to completing snap oregon form

The each, payment income, continue, c, Yes, cNoc, Yes, cNoc, Yes, c, No and DHS, Page, Can, use, prior, version segment needs to be applied to note the rights or responsibilities of both sides.

Filling in snap oregon form part 4

Finish by reading the next sections and preparing them accordingly: If, yes, complete, below c, No Job, cYesc, No New, amount, Date, of, the, change Job, Job, cYesc, No and cY, esc, No

step 5 to finishing snap oregon form

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