Fillable Form Fa-412 - Change Report (Page 2 of 3) in pdf

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FA-412 (10-17)

Page 2 of 3

RESOURCE CHANGES – Attach proof. You must report all resources that reach or exceed the resource limit for the benefits

your household is receiving: $2,000 for Cash Assistance and Nutrition Assistance, or $3,000 for Nutrition Assistance

households with at least one member age 60 or older; $1,000 single, or $1,400 two or more for State Assistance.

NAME OF PERSON (Last, First, M.I.)

NAME OF BANK/CREDIT UNION/SAVING AND LOAN

WHAT HAS CHANGED? (Check all that apply)

New Account

Closed Account

Deposit

Withdrawal

Cash

Checking

Savings

Stocks/Bonds

IDA

Other

ACCOUNT NO. (If checking, savings or IDA)

AMOUNT

DATE OF CHANGE (Checking, savings, other)

DATE IDA OPENED OR CHANGED

Complete the boxes below if anyone in your household received, bought, sold, traded or gave away any vehicle, RV, ATV or property.

NAME OF PERSON (Last, First, M.I.)

TRANSACTION

Received

Bought

Sold

Traded

Gave away

Gift

DESCRIPTION OF VEHICLE, RV, BOAT OR PROPERTY

CURRENTLY

CURRENT VALUE

AMOUNT PAID

AMOUNT OWED

DATE OF CHANGE

REGISTERED

Yes

EXPENSE CHANGES

Attach proof. Report changes in the amount of monthly dependent care expenses you are billed for the care of a

child or disabled adult in order for you to work, seek work, attend training or school. For Nutrition Assistance households ONLY – if you

pay court ordered child support, you must report changes of $50 or more in the amount of your court ordered monthly child support.

NAME OF PERSON(S)

MONTHLY AMOUNT

TYPE OF

NAME OF PERSON(S) OR COMPANY(IES) YOU

DID EXPENSE

PHONE NO.

RECEIVING CARE

EXPENSE

OWE OR HAVE PAID FOR THIS EXPENSE

Billed

Paid

(Last, First)

Child Support

Start

Stop

Change

Dependent Care

Date:

Medical

Child Support

Start

Stop

Change

Dependent Care

Date:

Medical

CHANGES IN SCHOOL ATTENDANCE – Attach proof. You must report changes in school attendance for any person in your household.

NAME OF PERSON

TYPE OF

DATE OF

NAME OF SCHOOL AND PHONE NO.

(Last, First, M.I.)

CHANGE

GRADUATION

Start School

Stop School

Start School

Stop School

CONTINUATION OF CHANGES

Will the changes you are reporting continue next month?

Yes

If no, please explain:

IMPORTANT INFORMATION, PLEASE READ

If you purposely hold back information about changes in your household or give false information, you will owe the Arizona Department of

Economic Security the value of any extra benefits you should not have received. You may be subject to penalties and/or criminal prosecution

under state and federal law.

•

FOR NUTRITION ASSISTANCE. If you or any member of your family are found guilty of an intentional program violation, you will be

disqualified for 12 months for the first offense 24 months for the second offense and permanently for the third offense and may be subject to

further prosecution under other state and federal laws. You or that person also may be fined up to $250,000, imprisoned up to 20 years, or

both; and barred by a court from the Nutrition Assistance program for an extra 18 months.

•

FOR CASH ASSISTANCE. If you or any member of your family are found guilty of an intentional program violation, you will be disqualified

for 12 months for the first offense, 24 months for the second offense and permanently for the third offense and may be subject to further

prosecution under other state and federal laws.

•

FOR MEDICAL ASSISTANCE. You must not knowingly withhold or give false information with the intent to receive or continue to receive

Medical Assistance. If the information you provide is incorrect, Medical Assistance may be denied or stopped. If you and/or your representative

are found guilty of knowingly giving false information, you and/or your representative will be subject to criminal prosecution, which could

result in fines, imprisonment and/or other penalties under state or federal law. You may also be required to repay AHCCCS the amount of

benefits paid during the period of ineligibility.

Information provided on this form may increase, decrease, suspend or stop your Nutrition Assistance, Cash Assistance or Medical Assistance.

A separate notice will be sent.

PLEASE SIGN AND DATE THIS FORM BEFORE RETURNING

SIGNATURE

DATE

FOR OFFICE USE ONLY

CHANGES REPORTED BY

ACTION REQUIRED

NO ACTION REQUIRED

EI’S COMPLETION DATE

EI’S INITIALS

C A

G A

M A

C A

G A

M A

The USDA is an equal opportunity provider and employer • DES/TANF Agencies are Equal Opportunity Employers/Programs • Under Titles VI and VII

of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the

Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in

admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To

request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language

assistance for DES services is available upon request. • Disponible en español en línea o en la oficina local.

Form Fa-412 - Change Report Page 2

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