Simplified Change Report For Supplemental Nutrition Assistance Program (Snap)
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4SM
Simplified Reporting System
Keep this for future use. It explains simplified reporting.
What is simplified reporting?
The Simplified Reporting System (SRS) is a way for some Supplemental Nutrition Assistance Program
(SNAP) clients to report changes. In SRS, you must report changes every six months answering the
questions on the Interim Change Report (DHS 0852) that is sent to you. You may also need to report
other changes during that six month period.
What to report?
Between report periods you must report the changes listed below. Report these changes by the tenth
day of the month after the change happens. You can report these to the Department of Human Services
(DHS) in writing, by phone or in person.
Household size
Amount
For SNAP, report when the total gross income for a month is
1 _____________ $1,287
more than the limits to the right. (Gross income is the
2 _____________ $1,736
amount before deductions, such as taxes.)
3 _____________ $2,184
4 _____________ $2,633
You do not need to report any other changes. But you may want
to report changes that will give you more benefits. For example, if
5 _____________ $3,081
your income goes down, your rent goes up, someone moves into
6 _____________ $3,530
7 _____________ $3,980
your home, you have out of pocket dependent care costs or medical
expenses for elderly or disabled individuals. You must continue to
8 _____________ $4,430
report changes for other program benefits.
More than 8 ______For each
additional person, add $451.
How do you use the six-month forms?
An Interim Change Report form will be mailed to you in the fifth month after you filed your last application.
• Wait until the reporting month is over to fill out the form. The form shows the reporting month
on the top of the front page.
• Answer all questions on the form. Answer them about the reporting month shown on the form.
• Include income for the whole month. Report your gross income (see item 2 above). List tips,
overtime, bonuses and commissions.
• Report the hours you worked.
• Attach proof of income. The proof must list the gross amount and the date paid.
Examples of kinds of proof include:
For work income and hours copies of pay stubs. If you do not get pay stubs, attach
written proof from your employer. The proof must list the gross amount, the date paid,
hours worked, employer’s name and phone number.
Other income award letters from Social Security, veterans’ benefits, unemployment
benefits, school grants or loans, bank statements showing interest income or copies
of child support checks.
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DHS 0853 (10/16), Recycle prior versions
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