Dhs-2240 - Change Report (State Of Michigan)
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1
2Enter DHS Office
Case Name:
Case Number:
Enter DHS Office Address 1
Date:
Enter DHS Office PO Box or Street
Enter DHS Office City/State/Zip
Enter Addressee Name
Enter Addressee Care Of
Enter Addressee PO Box or Street
Enter Addressee City/State/Zip
CHANGE REPORT
Use this form to report changes about anyone in your home within 10 days of the time you learn of them (For earned income,
within 10 days of receiving of your first payment.) If you cannot mail this form, report the change by calling your DHS specialist.
1. PERSONS IN YOUR HOME
List anyone who:
• Was Born--Enter newborn’s date of birth ______________________
• Died
• Got Married or Divorced
• Moved In or Out
• Began or Ended a Pregnancy
• Entered or Left a Nursing Home
• Is Temporarily Away From Your Home.
PERSON’S NAME
RELATIONSHIP TO YOU
DATE OF BIRTH
WHAT WAS THE CHANGE?
DATE OF CHANGE
2. HOUSEHOLD INCOME
Did anyone: start working, have a change in rate of pay, change employers, have a change in the number of hours worked per week of
more than 5 hours since last report that will continue for more than one month, stop working? Did anyone: start or stop getting Social
Security, a pension, UCB, child support or other unearned income. Did the household’s gross unearned income go up or down by more
than $50 per month since your last reported change? If receiving Medicaid only (except for Healthy Kids), you must report a change in
gross monthly unearned income of more than $25.
ATTACH a written statement SIGNED BY EMPLOYER, listing your work schedule (days and times) if you use day care and your
work schedule has changed.
SEND PROOF OF INCOME: Include your name and case number on it so we may return it to you.
IS THE
NUMBER OF
HOW OFTEN IS INCOME
CHANGE
PERSON WITH
DID INCOME
EXPECTED
HAS WORK
RECEIVED?
TYPE OF
AMOUNT
EXPECTED TO
START, STOP
INCOME
HOURS OF
SCHEDULE
INCOME
RECEIVED?
(Weekly, Bi-Weekly, Monthly,
CONTINUE?
CHANGE
OR CHANGE?
WORK PER
CHANGED?
etc.)
WEEK
(Yes/No)
3. EDUCATION OR WORK-RELATED ACTIVITIES
Did anyone participate in an approved employment-related activity, such as: a work participation program, high school completion, GED or
college, etc. ATTACH NEW CLASS SCHEDULE TO THIS FORM IF CHANGED.
NUMBER OF HOURS OF
HAS CLASS SCHEDULE
DID ACTIVITY START,
LIST PERSON IN ACTIVITY
TYPE OF ACTIVITY
EXPECTED
CHANGED? (Yes/No)
STOP, OR CHANGE?
PARTICIPATION PER WEEK
over
DHS-2240 (Rev. 9-11) Web
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