Form Fa-412 - Change Report
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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FA-412 (10-17)
Page 1 of 3
Family Assistance Administration
CHANGE REPORT
You only need to complete the sections that apply to the change(s) you are reporting.
AGENCY USE
To report changes in your household circumstances, complete and return or fax this form and any proof of the
:
change(s) to (602) 257-7031 when faxing from area codes 602, 480, or 623; or 1-844-680-9840 when faxing
DATE RECEIVED
from any other area code. You can also provide proof of your changes to the DES local office. To add a program
HOW RECEIVED:
to your existing case, visit any Department of Economic Security/Family Assistance Administration (DES/FAA)
Phone
Fax
Mail
or Tribal Temporary Assistance for Needy Families (TANF) office. A list of FAA local offices can be found at
MESSAGE RECEIVED BY:
https://eol.azdes.gov. You can also apply online at or by calling 1-855-HEA-PLUS
(1-855-432-7587).
•
Standard Reporting
Nutrition Assistance (NA), Cash Assistance (CA/TANF) – You must report changes before the 10th calendar day of the month following the month
the change occurs.
Insurance/Medical Assistance (MA) – You must always report within 10 calendar days of the day you know about the change. Complete the sections
that apply to the change(s) you are reporting. (If you receive MA, you are assigned to Standard Reporting)
•
Simplified Reporting – During your approval period for NA and/or CA, you only have to report when your gross earned and unearned income
(before deductions) is more than the income limit for your NA and/or CA family size (see the charts listed in the publication, “Your Change Reporting
Requirements” PAF-558).
NAME (Last, First, M.I.)
CASE NO.
SOCIAL SECURITY NO.
DATE OF CHANGE
NEW ADDRESS/PHONE NO. CHANGES
Attach proof of new rent, mortgage amounts and new utility costs.
HOME ADDRESS (No., Street, City, State, ZIP Code)
HOME OR MESSAGE PHONE NO.
MAILING ADDRESS, IF DIFFERENT FROM ABOVE (P.O. Box, Apt./Space #/ No., Street, City, State, ZIP Code)
COUNTY YOU LIVE IN
DATE OF COST CHANGE
NEW RENT OR HOUSING COST
I PAY FOR:
Water
Phone
Electric
Gas
Other
None
$
A/C
Evaporative Cooler
Central Heating
Space Heater
Other
HEATING AND COOLING SOURCE:
LANDLORD’S NAME
LANDLORD’S ADDRESS (No., Street, City, State, ZIP Code)
PHONE NO.
INCOME CHANGES
Attach proof
EARNED INCOME – The payment you receive from working at a permanent or temporary job, any odd jobs, self-employment, babysitting, tips, etc., is
earned income. If you receive Nutrition Assistance (NA) ONLY, and are assigned to the Standard Reporting requirement, you must report changes in
earned income of more than $100 a month.
NEW
HOURS
NAME OF PERSON
EMPLOYER’S NAME
EMPLOYER’S
TIPS PER
HOW OFTEN
DID INCOME
HOURLY
PER
RECEIVING INCOME
AND ADDRESS
PHONE NO.
WEEK
PAID
PAY
WEEK
Start
Stop
Change
$
$
Date:
Start
Stop
Change
$
$
Date:
UNEARNED INCOME – The payment you receive from unemployment benefits, veterans’ benefits, disability, retirement/pensions, gifts, contributions,
child/spousal/medical support, SSA, SSI, BIA assistance, money from roomers or boarders, educational income, winnings, land lease, interest, free
housing or utility allowance, etc., is unearned income. If you receive Nutrition Assistance (NA) ONLY, and assigned to the Standard Reporting requirement,
you must report changes in unearned income of more than $50 a month.
NAME OF PERSON
TYPE OF
AMOUNT
HOW OFTEN
CONTACT
DID INCOME
PHONE NO.
RECEIVING INCOME
INCOME
RECEIVED
RECEIVED
PERSON
Start
Stop
Change
$
Date:
Start
Stop
Change
$
Date:
HOUSEHOLD MEMBER CHANGES
Attach proof of income and resources for new members, including children and newborns.
Report when someone moves in or out of your home, when a household member is in the hospital, when you or a member of your household
has a baby, the death of a household member, change in your or a household member s marital status, or if a parent is no longer disabled.
SOC. SEC. NO.
Add to
FULL NAME
RELATIONSHIP
BIRTHDATE
(Optional if not
your CA,
IS PERSON
DATE MOVED
(Last, First, M.I.)
TO YOU
applying)
NA or MA
CA
NA
Pregnant
Disabled
U.S Citizen
In:
MA
Student
Receiving Money
Out:
CA
NA
In:
Pregnant
Disabled
U.S Citizen
MA
Student
Receiving Money
Out:
FEDERAL TAX FILING CHANGES
Anyone plan to file Federal Income Taxes?
Yes
No
If yes, who?
Will claim dependents on own tax return?
Yes
No
If yes, list dependents’ names:
Claimed as dependent on someone else’s tax return?
Yes
No
If yes, name of tax filer claiming this person:
FILING STATUS:
Head of Household
Qualifying Widow(er)
Single
Married-Filing Separate Return
Married-Filing Joint Return - spouse’s name:
See page 2 for USDA/EOE/ADA/LEP/GINA disclosures
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