Form Fsp-922 - Change Report Form For Food Stamp printable pdf download

FSP-922 (Rev. 5/10)

(Page 1)

CHANGE REPORT FORM FOR FOOD STAMP NON-SIMPLIFIED REPORTING CASES

This form is to be used to notify your food stamp office of any changes in your household's circumstances. You can also

call _______________________________________ to report changes.

YOU MUST REPORT THE FOLLOWING CHANGES WITHIN 10 DAYS OF FINDING OUT ABOUT THEM.

ALL CHANGES IN HOUSEHOLD COMPOSITION (SUCH AS SOMEONE ENTERING OR LEAVING YOUR

HOUSEHOLD).

CHANGES IN RESIDENCE AND ANY CHANGES IN SHELTER COSTS (SUCH AS RENT OR MORTGAGE

COSTS) WHICH RESULT FROM MOVING.

NEW EARNED INCOME AND/OR UNEARNED INCOME (SUCH AS, EMPLOYMENT, UIB, CHILD SUPPORT, SSI,

ETC).

INSTRUCTIONS: COMPLETE THE INFORMATION BELOW AND RETURN IT TO THE FOOD STAMP OFFICE.

NAME:

___________________________________DAYTIME PHONE# _____________________

ADDRESS: _____________________________________________CASE NO. ________________

THIS IS TO INFORM YOU THAT:

( )

I (we) have moved to ___________________________________________________ on ________________

(give new address)

(date moved)

( )

A new member has been added to our household.

Date Added:_______________ Name:________________________________________________

Relationship:________________

Date of Birth:___________ Social Security#:_________________

Source of income:______________________________________

( )

A member has moved out of our household.

Name:____________________________________

Date moved:___________________________

Relationship:______________________________

Source of Income:_______________________

( )

This change will happen this month only. ( )Yes ( ) NO, IT WILL CONTINUE.

( )

I (we) have new earned income ____________________

New unearned income ____________________

( )

Other changes you might want to report but are not required to report: (such as changes in shelter costs

even if you have not moved, medical expenses, etc.)

________________________________________________________________________________________

REMEMBER: you are eligible for the standard utility allowance, you must utilize it. Households with elderly or disabled

members may qualify for the excess shelter deduction.

ANY MEMBER OF YOUR HOUSEHOLD WHO BREAKS ANY OF THE FOLLOWING RULES ON PURPOSE WILL NOT

BE ABLE TO GET FOOD STAMP BENEFITS FOR 12 MONTHS AFTER THE FIRST TIME, 24 MONTHS AFTER THE

SECOND TIME, AND PERMANENTLY AFTER THE THIRD TIME. A COURT CAN ALSO ORDER THE PERSON OFF

FOOD STAMP BENEFITS FOR AN ADDITIONAL 18 MONTHS.

THE PERSON CAN ALSO BE FINED UP TO

$250,000, SENT TO JAIL FOR UP TO 20 YEARS OR BOTH. UNDER OTHER FEDERAL LAWS, ADDITIONAL

CRIMINAL OR CIVIL ACTION MAY BE TAKEN AGAINST THE INDIVIDUAL.

Form Fsp-922 - Change Report Form For Food Stamp

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