Change Report Form - Minnesota Department Of Human Services
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*DHS-2402-ENG*
Change Report Form
dHS-2402-enG
10-10
nAme
cASe numBer
AddreSS
Worker nAme
Worker PHone numBer
Purpose: This form is to report changes to your county human services agency which may affect your eligibility or benefit level.
Instructions: Fill out this form only if you have changes to report. If you get cash assistance, report any change within 10
days. If you get Food Support, report changes by the 10th of the month following the month of the change. For example, if
a change happens in March 2009, you must report the change by April 10, 2009. Use a separate sheet if you need more room. You
may also call your worker to report a change. If you don't know whether to report a change, call your worker.
Note: Return your completed form to your county human services agency. Remember to sign and date it. If you do not know
your county agency's address, call your worker. Do not return this form to the Minnesota Department of Human Services
Issuance Operation Center (IOC) in St. Paul.
You must send proof of changes
Change in address
county moved to
county moved from
I (we) moved to:
AddreSS
neW PHone numBer
cIty
StAte
ZIP code
dAte moved
Have you either moved on to a reservation or left a reservation in the last month? Yes
No
Change in people in my home
_____________
Total number of people now in my home:
nAme
relAtIonSHIP to you
Moved
Married
Died
Born
Date of change
Has income?
___/___/___
Yes
In
Out
No
SSn
BIrtH dAte
Source of income? _______________________ How often paid? ______________
nAme
relAtIonSHIP to you
Moved
Married
Died
Born
Date of change
Has income?
___/___/___
Yes
In
Out
No
SSn
BIrtH dAte
Source of income? _______________________ How often paid? ______________
Do any of the new people in your home buy fix or eat meals with you?
Yes
No
If yes, name(s) _________________________ __________________________
Change in savings or property
Types of proof: bank statement, property statement
(Cash and health care only)
Savings/checking, certificates of deposit, IRAs, etc.
open $____________
closed
Land or buildings
PlAce
Amount PAId/receIved
dAte PAId/receIved
Bought
Sold
Change in vehicles
Types of proof: bill of sale, title certificate
(Cash and health care only)
Report if you bought, sold, traded, were given or gave away any vehicles (examples-cars, vans, trucks, motorcycles, off-road
vehicles, boats).
Bought by or given to someone in your home
Sold, transferred, or given away by someone in your home
HouSeHold memBer
dAte of trAnSActIon
money receIved If Sold
tyPe of veHIcle
mAke
model
yeAr
vAlue
This information is available in alternative formats to individuals with disabilities by calling your county worker. TTY users can call
through Minnesota Relay at (800) 627‑3529. For Speech‑to‑Speech, call (877) 627‑3848. For additional assistance with legal
rights and protections for equal access to human services programs, contact your agency’s ADA coordinator.
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