Form Dss-Ea-310 - Medical Assistance/tanf Change Report Page 2
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2If self-employed, describe type of work and the change in income below:
Other income changed. Complete all that apply
Source of Income
Amount
How often received?
Source of Income
Amount
How often received?
Unemployment
Alimony Received
Pensions
Net Farming/fishing
Social Security
Net rental/royalty
Retirement
Other income type
Accounts
Someone in the household is pregnant. If checked, complete questions below:
Name of person that is pregnant: _____________________________ How many babies are expected? _______
Someone gave birth to a child. If checked, complete questions below:
Date of birth: ______________ Name of newborn: _______________________________ Gender: ____________
For Medical Assistance Only:
Health insurance started, stopped, or company changed?
List the policy # ___________________________
Co. Name/address: _____________________________
Describe the change: ______________________________________________________________________
For TANF Only:
CHECK THE SECTION(S) THAT HAVE CHANGED, EXPLAIN & ATTACH PROOF:
Bank accounts/resources changed. Describe new accounts, increased amounts in existing accounts,etc.
___________________________________________________________________________________
Bought, sold, traded, or gave away vehicles (cars, trucks, boats, etc). Describe the change:
_____________________________________________________________________________________
The amount you pay for child support payments started, stopped, or changed. Describe
who the payment is for, who it is paid to, and the change in payment:
_____________________________________________________________________________________
School attendance changed. Provide name, change that occurred, and date of occurrence:
____________________________________________________________________________________
I understand that the information on this form is subject to verification by Federal, State and local officials to determine that
such information on this form is correct and complete. If any information is found to be incorrect, benefits may be reduced or
terminated and I may be responsible for paying the benefits back. I declare and affirm under penalties of perjury that this
report form has been examined by me and to the best of my knowledge and belief is in all things true and correct. I
understand I may be subject to criminal prosecution for knowingly providing incorrect information.
________________________________________________________
___________
Signature
Date
Additional Comments: _____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Parent category: Medical