Form Scdjfs 7029 - Change Report, Voter Registration And Information Update Form
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Family and Adult Services
Change Report
Type of report:
Date of report:
Report taken by:
Telephone number where you can be
Walk-In
Call Center
reached:
Cashier
Other ___________________
Case manager
Caseload:
Person reporting: (if different than case name)
Case number:
Last four digits of SSN:
(CRISE)
Change in address, mailing address or household expenses: (VERIFICATION IS MANDATORY)
Address
Apt
Address
Apt
City
State
Zip Code
City
State
Zip Code
How many people
The above address is:
Effective date of the:
Did you move outside Summit County?
New rent amount:
live at the new
Move
$
Residence address
Yes
No If yes, list name of new county?
address?
Expected move
Mailing address only
Are utilities included?
_____________
_____________________________________
Yes
No
Did you move in with anyone who currently
Will you receive housing assistance for rent or a utility
Will you share household expenses?
receives public assistance?
reimbursement check?
Yes
No If yes, what type?
Yes
No If yes, with whom?
Yes
No If yes, list amount.
___________________________________
______________________________
Rent $_________ Utility reimbursement $__________
Change in income:
Type of change: (Select)
Effective date:
Employment
Social Security
VA Benefits
Retirement/Pension
Child Support
SSI
Workers Comp
New amount:
Unemployment
SSD
Other
_________________________________________
$
(Specify)
Change in employment:
Name of new employer or old employer:
Hire date:
End date:
Reason for ending employment:
Date expecting first pay? Date of final pay:
Hours per week:
Hourly pay rate:
Pay frequency:
Child care expenses:
(if report-
ing loss of employment)
$
Request for closing:
Reason:
Effective date:
Change in household:
Name(s) Last:
First:
MI:
SSN (last 4 digits)
Date of birth
Effective date
Add
Remove
___
Add
Remove
___
Add
Remove
___
If you are unable to obtain any of the requested verifications, please contact your case manager immediately. Failure to submit the required
verifications may result in a delay or termination of benefits. THE FOLLOWING CHECKED () FORM(S) MUST BE COMPLETED AND
RETURNED TO YOUR CASE MANAGER BY _________________.
7002 Wage Verification
Client, authorized representative
Date
Other __________________________________
DJFS representative
Date
Distribution: Client, case manager, supervisor
SCDJFS 7029
Rev 06/16
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Parent category: Legal