Form CF-ES 3052A at a glance
What it is: The CHANGE REPORT FORM is form CF-ES 3052A, May 2016.
Who signs: PLEASE READ AND SIGN: you understand and agree that DCF, Public Assistance Fraud (PAF), and authorized Federal Agencies may verify the information you give on this form and at your interview. Information may be obtained from your past or present employers. You will report any change in your situation according to program requirements. If any information is incorrect, benefits may be reduced or denied and you may be subject to criminal prosecution or disqualified from the program for knowingly providing incorrect information. You can be prosecuted if you provide false information or hide information. You understand that you may be entitled to more food assistance if you report that your household's income has decreased or stopped; if you do not report that your household's income has decreased or stopped, then you will not get an increase in your food assistance benefit amount; and if you do not report increases in income or that income has started, then there may be penalties. Write Your Signature and Today's Date.
Where and when to file: Report the change(s) by filling in the spaces on the form. Continue your reply on the back of this form if you need to. You can mail this form or bring it to the office. If you do not understand this form, call your local office and someone will help you. You can also report change(s) through My Account.
A filled-in Form CF-ES 3052A example: a household reports a move
How to fill out Form CF-ES 3052A, box by box
Name, case number and phone numbers
Fill in Name, Case No, Address and the Phone numbers where you can be reached.
The City/State/Zip, Home and Other boxes go with Name, Case No, Address and Phone numbers. Food assistance households only have to report a change when the total monthly gross income exceeds 130% of the Federal Poverty Level for the household size and when work hours of able bodied adults fall under 20 hours per week when averaged monthly. The household must report these changes within 10 days after the end of the month of the change.
Is this a new address, rent and utilities
Under Is this a new address? mark Yes or No and write the Date moved.
Write the New rent / mortgage payment and mark per Month, Week or Other.
Mark Yes or No for Do you pay separately for utilities? and Yes or No for Do you have a heating or cooling expense?
1. PERSONS
Under 1. PERSONS mark Moved In or Moved Out and write the Date moved in / out; for each person fill in NAME, RELATIONSHIP TO YOU, INCOME / ASSETS, DATE OF BIRTH / DEATH, SOCIAL SECURITY NUMBER and DISABLED (Yes No).
2. INCOME CHANGES
Under 2. INCOME CHANGES mark New income source, Rate of pay/number of hours increase/decrease or Income loss; write the Rate of pay/number of hours increase/decrease, the Date & amount of first/last payment and the First/last day of work, and for Income loss the Reason employment/income stopped.
For each income change fill in whose income, what income source changed, paid/received (weekly, every 2 wks, biwkly, monthly, other), day of week pay / income received and gross income amount.
3. ASSET CHANGES
Under 3. ASSET CHANGES, you must report if the money you have in cash, checking, savings, stocks, bonds, etc., reaches $2,000 or if you buy/sell a vehicle, house, property, etc. (checked November 7, 2026)
Mark New, Bought, Sold, Traded, Transferred, Depleted or Other (and write the Other), then fill in WHOSE ASSET, WHAT ASSET / YEAR, HOW USED and AMOUNT.
4. FUTURE CHANGES
Under 4. FUTURE CHANGES, mark Yes or No for Do you think the changes you reported will stay the same next month? If no, please explain.
5. You can apply to register to vote here
Under 5. You can apply to register to vote here, check YES if you would like to apply to register to vote or update your voter registration information. If you check the NO box or do not check a box, you will be considered to have decided not to apply to register to vote or update your voter registration information. Checking YES, NO, or leaving this question blank will not affect your receipt of benefits.
Please read and sign
Mail this form or bring it to the office
Sources
[1] CHANGE REPORT FORM, CF-ES 3052A (May 2016), Florida Department of Children and Families (the Official source link on this page).
