Form Dss-Ea-310 - Medical Assistance/tanf Change Report
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2Case #: ___________________ Section: __1__
DSS-EA-310 03/16
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
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 Person
Date 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
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Parent category: Medical