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2584-EG - Change Report Form

This document is a change report form used to report changes to benefits recipients in Nevada. It requests information about changes in address, household members, income, expenses, and resources. The form must be completed and signed to report any changes that may impact eligibility for benefits within mandated reporting timeframes.

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kevin
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39 views2 pages

2584-EG - Change Report Form

This document is a change report form used to report changes to benefits recipients in Nevada. It requests information about changes in address, household members, income, expenses, and resources. The form must be completed and signed to report any changes that may impact eligibility for benefits within mandated reporting timeframes.

Uploaded by

kevin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STATE OF NEVADA

DEPARTMENT OF HEALTH AND HUMAN SERVICES RICHARD WHITLEY, MS


Director
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
ROBERT THOMPSON
Administrator
JOE LOMBARDO
Governor

CHANGE REPORT FORM


THE LAW SAYS YOU MUST REPORT CHANGES TO US WITHIN 10 DAYS AFTER THE CHANGE HAPPENS IF YOU ARE
RECEIVING SNAP BENEFITS AND BY THE 5TH OF THE FOLLOWING MONTH FOR TANF AND/OR MEDICAL ASSISTANCE.
Fill in the spaces below. (You can write an explanation on a separate sheet of paper.) You can mail or bring this report into the office.
PLEASE PROVIDE PROOF OF THE CHANGES.
NAME SOCIAL SECURITY NO.

ADDRESS APT # HOME PHONE CELL PHONE

E-MAIL
CITY/ZIP CODE
Is this a new address? YES NO
MAILING ADDRESS (If different)

PEOPLE CHANGES: Did someone move in move out or have a baby? Please provide details below.
DATE MOVED DATE OF SOCIAL
NAME RELATIONSHIP
IN OR OUT BIRTH SECURITY NO.

Is the member moving in a tax filer? YES NO


Is the member moving in a tax dependent? YES NO
If yes, who claims this member as a tax dependent?

INCOME AND JOB CHANGES


Did someone get a new job? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per month
Medical insurance available? YES NO Effective Date
Did someone end a job? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per month
Medical insurance available? YES NO Effective Date
Did someone change work hours or pay? YES NO Who? When?
Place of Employment Hours worked per week
Hourly Rate Date of First Paycheck
Day of the week paid Pay Frequency
Are tips received? YES NO Amount per month
Medical insurance available? YES NO Effective Date

2584 - EG (216.0.0)
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OTHER INCOME CHANGES (Unemployment benefits, Social Security benefits, SSI, disability, child support, etc.)
Explain type of income and change:

How much is received each month? $ Who receives this income?

EXPENSE CHANGES

New rent/mortgage payment? $ Do you pay utility bills? YES NO


Child Care Expenses? $
Medical expenses for the elderly (60+) or disabled?
Does anyone pay part of these expenses? Explain:

New child support you are ordered to pay? $

RESOURCE CHANGES

You must report any changes in resources (checking/savings accounts, bonds, home/land, boat, life insurance, vehicles, etc.).
Include specific information about the opening, closing, purchasing, selling of, or changes to resources. Explain:

OTHER CHANGES NOT LISTED ABOVE

i.e. Pregnancy

PLEASE READ AND SIGN: “I understand the penalty for hiding information or giving false information. I understand that I must repay the value of
any benefits I get because I did not report changes or failed to report changes timely. I understand I may be disqualified from getting benefits. I can
be fined or prosecuted or both if I do not tell the truth. I agree to provide proof of any changes if asked to do so. My answers on this form are true,
correct and complete to the best of my knowledge.”

/ /
Client Signature Print Name Date Telephone Number

PROVIDE PROOF OF CHANGES


IF WE CHANGE YOUR BENEFITS WE WILL SEND YOU A NOTICE.

2584 - EG (216.0.0)
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