Pa564 – Fill Out and Use This PDF

Si necesita formulario en español, communiquese con su trabajador immediatamente, tiene que completar, firmar y devolver esta forma la "County Assistance Office" para la fecha de vencimiento que se indica o su caso será cerrado, incluyendo su assistencia médica, y/o sus cupones de comida (7 CFR 273.12 (a)(1)(vii) and 55 PA Code 133.23 (a)(1)(viii), 133.84(d), 140.401, 140.513(3), 201.1, 201.3).

We must review your eligibility so you may continue to receive benefits.

YOU MUST:

. Review and answer the questions on this form (if you need additional space for any of the questions, use a separate piece of paper and attach it to this form).

. Sign the certification section. An unsigned form is considered incomplete.

. Mail completed form in the return envelope provided or fax the form to the

County Assistance Office with:

. Proof of all household members' income from work.

. Proof of any changes reported on this form.

Please read the instructions on page A and if you need help or if you have questions about the proof needed to verify changes, call your caseworker or the Change Center.

Please return ALL pages of this form in the enclosed envelope.

If you wish to claim good cause, sign and include page A.

Notice ID: 0

Last NameFirst NameM.I.Date of Birth

Did anyone move into or out of your household? Yes____ No____ If yes, list who and their relationship to you.

Did any household member start a new job, change a job, or stop working? Yes ___ No ___ If yes, list any changes, such as job start date, end date, date of first pay, how often paid.) Provide proof (pay stubs, employer statements, etc.)

Did any household member lose or start receiving income or have a change in amount? Yes ___ No ___

If yes, list any changes. Provide proof (award letter, support court orders, etc.)

If you receive food stamps and you have moved, what are your shelter (rent/mortgage) and utility costs? Do you pay for your own heating and/or air conditioning? Yes ___ No ___

*Answering these questions may help you receive more food stamp benefits.

Did any household member have a change in the amount he is requested to pay? Yes ___ No ___ If yes, list any changes. Provide copy of support court order or letter and proof of payment.

* You do not have to answer this question or provide proof. Answering this question and providing proof may help you to remain eligible or receive more benefits.

* You do not have to answer this question or provide proof. Answering this question and providing proof may help you to remain eligible or receive more benefits.

Has the information in this section changed? Yes ___ No ___

Does any household member have resources not listed above? Yes ___ No ___

If you answered yes to either question, list any changes. Provide proof (copy of bank statement, vehicle registration, etc.)

I swear that the information given on this form is complete and correct to the best of my knowledge. I agree to report any changes in circumstances that may affect my eligibility or the amount of cash, Medicaid and/or food stamp benefits. I understand that willful failure to give accurate information or to report changes may result in a fine or imprisonment or both. I understand that changes in income, circumstances, and/or other factors as reported on this form may cause my cash assistance, medicaid and/or food stamp benefits to be increased, decreased or stopped.

INSTRUCTIONS

Your household circumstances require you to report semiannually (every 6 months). The information on the semiannual reporting form is needed to determine your continued eligibility for cash, food stamps, Extended Medical Coverage and/or Medicaid. It is also needed to calculate the amount of your monthly cash and/or food stamp benefits. You must give us information for the reporting month shown on page 1 of the form. You are asked to provide child care information: failure to do so could lead to lower benefits or ineligibility.

Note: You may report changes at any time if the change would increase your benefits (such as if you lose your job or your hours of work decrease).

When answering the questions, you must give us information for all persons included in your cash, food stamps and/or Medicaid benefits. This includes stepparents and information for sponsors of aliens, even if the sponsor does not live in your home. You can use a separate sheet of paper to explain any of your answers or give additional information. A separate sheet of paper must be sent in with the form.

You must complete, sign and return the form to the county assistance office by the date shown on page 1 of the form. IF YOU NEED HELP TO COMPLETE THE.FORM, CALL YOUR CASEWORKER OR CHANGE CENTER.

. NOTICE

.If the form is late or incomplete, you may not receive you cash and/or food stamp benefits on time.

If you DO NOT return the form, action may be taken to close your case. This action may include your cash assistance, food stamps and/or Medicaid (55 Pa Code 133.84(d), 104.401, 140.513(3), 201.1, 201.3 and 7 CFR 273.12 (a)(1)(viii)).

.If you disagree with the decision to reduce or stop your benefit(s), you have the right to appeal. You will be sent a notice to tell you about any proposed reduction or stoppage of your benefits.

If your case is closed, you may have to complete a new application and be otherwise eligible to have benefits restored.

GOOD CAUSE

YOU MAY CLAIM "GOOD CAUSE" if you have good reason for not completing the form or for returning it late. To claim "good cause", you must state your reason(s) in the space below, sign your statement and return this form to the county assistance office as soon as possible, within 30 days from the due date. You may also claim "good cause" orally by contacting your caseworker, but you must also return this form to the county assistance office as soon as possible, within 30 days from the due date.

I AM CLAIMING "GOOD CAUSE" BECAUSE:

CLIENT SIGNATURE:

For DPW use ONLY

-PAGE A-

Important Information

About the Department of Public Welfare's Notice of Privacy Practices.

If you need a free translation of this information, contact your County Assistance Office.

YOU MAY REQUEST A COPY OF THE DEPARTMENT'S

NOTICE OF PRIVACY PRACTICES

The Department of Public Welfare's Notice of Privacy Practices explains how information about you is used and

disclosed. This Notice is available at any time through your County Assistance Office and online at

www.dpw.state.pa.us. If you would like us to send you a copy of the Notice of Privacy Practices, please contact your caseworker. You may also request a copy in person at your County Assistance Office.

USTED PUEDE SOLICITAR UNA COPIA DEL AVISO DE LAS

NORMAS DE PRIVACIDAD DEL DEPARTAMENTO

EI Aviso de las Normas de Privacidad del Departamento de Bienestar publico explica como se utiliza y divulga

información sobre usted. EI Aviso esta disponible en cualquier momento en la Oficina de Asistencia del Condado o en linea en www.dpw.state.pa.us. Si desea que nosotros le enviemos una copia del Aviso de las

Normas de Privacidad, comuníquese con su asistenete social. Tambíen puede solicitar una copia un persona en

También puede solicitar una copia un persona en la Oficina de Asistencia del Condado.