Interim Change Report Form – Fill Out and Use This PDF

Enter the Program, Branch, Case number, Worker ID and Case name.

This is not an application.

To prevent a possible delay in receiving your benefits, return this form between the 1st and 10th day of the month. If this form is not received by the last day of the month, 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. 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.

Answer the questions for the report month.

Enter the Home address, City, State, ZIP code and Phone number.

Enter the Mailing address, City, State, ZIP code and Message number.

Do you pay for housing? Mark Yes or No. If yes, mark Rent or Mortgage and enter the Amount you pay monthly.

Enter the Amount you pay monthly, the Homeowners insurance, if separate, per year and the Property tax, if separate, per year.

Say how your home is heated: Wood, Oil, Electric, Gas or Other. Is the heating expense included in the rent? Mark Yes or No.

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

List each person living in your home: Name (last, first, middle), Relationship to you, Sex (circle one), Date of birth and Wants SNAP (circle one).

For Purchase and prepare meals with you, circle one.

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

Does anyone get money from any other source? If yes, complete the row and attach proof. Some examples are: Social Security, Unemployment Compensation, Veterans benefits, Child support, Workers' Compensation and Loans/gifts.

Enter the Name of person who got other money, Source of other money, How often paid, Amount of each payment, Amount this month and Will this income continue (Yes or No). If income will change, give the new amount.

What is the reason for the change and when it will change?

(4) Does anyone work? Mark Yes or No. If yes, complete the job boxes. List each job for each person who works. Attach proof of the income received in the report month.

The report month is listed at top of page 3.

If self-employed, check here. For Job #1, Job #2 and Job #3, enter the Person working and the Employer's name and phone number.

For each job, enter the Job title, Hourly pay, Hours (per week), How often paid (weekly, monthly), Pay dates, Tips per week and Draws, overtime pay, bonuses or commissions. If you are not paid by the hour, explain your income here.

Will this income continue? Mark Yes or No. If income will change, give the reason for the change here, the New amount and the Date of the change.

Does anyone in your household work as a volunteer? Enter the Name of volunteer and Hours per week.

If anyone living with you is court-ordered to pay child support, has the court-order changed? Mark Yes or No. If yes, enter the 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.

Sign on the Signature of person completing this form line, and enter the Date and Phone.

There are penalties in the SNAP program. If you knowingly do the following, which is to use EBT cards which are not yours, transfer your EBT cards to other people, or acquire or possess EBT cards which are not yours, you may be guilty of a felony or misdemeanor, fined, put in prison or ineligible for food benefits for a period of time.