Form Dss-8131 - Change In Situation Report - Economic Independence Section
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1FOR AGENCY USE ONLY
County _________________ District # ____________________
Refer to:
WFFA
SA
CHANGE IN SITUATION REPORT
Food Stamps
LIEAP
MA
Services
Name
____________________________
Case
No:______________________________
Date_______________________
If your situation changes, you must report this within ten (10) days. If you fail to do so, you may have to pay back
some or all of the money you were paid, go to court, or both. If any of the items below have changed, complete this
form, sign it, and return it to our office or contact your worker, _________________________________ at this number:
__________________________________.
1. Have you moved? No__________ Yes _________
If yes, give your new address
Directions to your new address
Give your phone number or a number where a message may be left for you: ______________________________
2. Has anyone moved into or out of your home? No ________________ Yes ___________ If yes list name(s) of
person(s)
Relation to you
3. Are you or anyone in your household receiving:
No
Yes
If yes, who
Amount
a) unemployment benefits
b) Social Security
c) veteran's benefits
d) worker's compensation
e)
retirement
f)
support
g)
insurance check
h) housing authority payment
i)
railroad retirement
j)
SSI
k) other
4. Are you working full-time, part-time, or doing anything you get paid money for? No _______ Yes _______. If yes,
give name and phone number of employer
When did you start working? ________________________ When is your first pay date? ________________________
How many hours do you work per week? _______________
What are you paid per hour? ___________________
How often are you paid? _____________________________
5. Has your youngest child reached age 6? No _________ Yes ______________
6. Has any child 16 or over stopped school? No __________ Yes __________ If yes, is he/she working?
No ______ Yes ______ If yes, give name of employer _________________________________________________
7. Have you opened a bank account? No ______ Yes ______ If yes, give name of bank _______________________
8. Are you buying any land or property? No ______ Yes ______ If yes, Where? County ______________________
City, town, or township _______________________________State _______________________________________
9. Have you sold any land or property? No ______ Yes ______ If yes, Where? County _______________________
City, town, or township _______________________________State _______________________________________
10. Other changes
Signature of Applicant/Recipient
Date
DSS-8131 (Rev.7-97)
Economic Independence Section
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