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The Interim Change Report form is a crucial document for individuals participating in the Supplemental Nutrition Assistance Program (SNAP). This form ensures that you remain eligible for food benefits by providing updated information about your household and financial situation. You'll need to report details such as your program, branch, case number, case name, and worker ID at the top of the form. It’s essential to submit this report between the 1st and 10th of the month to avoid any delays or interruptions in your benefits. You'll want to answer all questions accurately for everyone living with you, detailing both earned and unearned income sources. Remember to attach any necessary proof of income to support your claims. Also, it’s important to understand that returning the form late or leaving it incomplete could result in significant delays in receiving your benefits. The form includes a section on non-discrimination policies, emphasizing that assistance is provided equitably regardless of age, race, gender, or other factors. Lastly, your signature on the form confirms that the information you provide is true and that you understand how it may affect your benefits. Your cooperation plays a vital role in ensuring that you continue to receive the support you need.

Interim Change Report Example

Program: Branch: Case number:

Case name:

Worker ID:

Interim Change Report For

Supplemental Nutrition Assistance Program (SNAP)

To prevent a possible delay in receiving your benefits, please return this form between the 1st and 10th day of _________________________________.

If this form is not received by the last day of

_____________________ your benefits may stop.

To continue your benefits

You must turn in this form to get benefits.

Answer the questions for yourself and all persons living with you for _________________________________ .

Attach a sheet of paper if you need more room.

Attach proof of what you report.

If you need help with this form, call the number at the top. You may call collect, if necessary.

Your benefits may get delayed if:

You return this form after the 10th of the month, or

It is incomplete.

This is not an application

How to use this form

This form is needed to show that you are still eligible for food benefits. Answer all questions about all who live with you. Give all household income from all sources. This includes earned and unearned income for all household members.

Our discrimination policy

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age,

race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.

You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at:

Governor’s Advocacy Office

500 Summer Street NE, E17, Salem, OR 97301 Email: [email protected]

1SNAP clients are protected against political belief discrimination.

2Sexual orientation is protected by the State of Oregon, but not federal laws.

Answer all questions. Be sure to sign and date on the back.

DHS 0852 (10/18) Page 1, Can use prior version

“Equal opportunity is the law!”

The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) are equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals with disabilities.

To file a complaint with USDA, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 or call 202-720-5964 (voice and TDD).

By signing this form, I understand and agree that:

I must return this information to get benefits.

I can talk to my worker or a person in charge if I have questions about this form.

I register for the Oregon Food Stamp Employment Transition (OFSET) program all people in my household who want food benefits.

My answers on this form will affect my benefits. This information may cause my benefits to go up, down or stop. I will get a notice explaining how my answers on this form will affect my benefits and how to ask for a hearing.

If I quit a job without a good reason, I may lose food benefits for myself.

There are penalties in the SNAP program for doing any of the following:

If you do the following...

You will lose food benefits...

 

 

 

 

Hide information or make false statements;

12 months for the first offense;

Use Electronic Benefit Transfer (EBT) cards that

24 months for the second offense;

 

belong to someone else;

Permanently for the third offense.

Use food benefits to buy alcohol or tobacco;

Trade or sell benefits or EBT cards;

Dump containers only for the cash redemption value;

Resell food bought with food benefits for cash.

Trade food benefits for controlled substances

24 months for the first offense;

 

such as drugs.

Permanently for the second offense.

Trade food benefits for firearms, ammunition

Permanently.

 

or explosives.

 

 

Trade, buy or sell food benefits of $500 or more.

Permanently.

 

 

 

 

Give false information about who you are or

10 years for each offense.

 

where you live so you can get extra food benefits.

 

 

You can also be fined up to $250,000 or put in prison for up to 20 years, or both, for doing these things. You may also be charged under other Federal laws.

If you knowingly do the following...

You may be...

 

 

 

• Use EBT cards which are not yours;

Guilty of a felony or misdemeanor;

Transfer your EBT cards to other people;

Fined;

Acquire or possess EBT cards which are not yours.

Put in prison;

 

 

Ineligible for food benefits for a period of time.

 

 

 

 

DHS 0852 (10/18) Page 2, Can use prior version

Program: Branch:

Case name:

Worker ID:

Case number:

If you are not registered to vote where you live now, would you like to apply to register

to vote today? c Yes c No Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency.

(1) Answer the questions for (report month):

Home address:

Mailing address:

City:

City:

State:

State:

ZIP code:

ZIP code:

Phone number:

Message number:

Do you pay for housing?

c Yes

 

c No (If yes, complete below.)

c Rent c Mortgage

 

 

 

 

 

 

Amount you pay monthly?

 

 

Homeowners insurance, if separate:

 

Property tax, if separate:

$ ____________

 

 

$ ____________ per year

 

 

$ ____________ per year

How is your home heated?

c Wood

c Oil

c Electric

c Gas

c Other: ___________________

Is the heating expense included in the rent? c Yes

c No

 

 

 

 

 

 

 

 

 

Check all utilities that you pay.

c Electricity

c Phone

c Water/sewer

c Wood

 

 

 

c Natural gas

c Propane

c Garbage

 

c Oil

(2)Who lives at this address with you? (List each person living in your home.)

 

Relationship

Sex

Date of

Wants SNAP

Purchase and

Name (last, first, middle)

prepare meals

to you

(circle one)

birth

(circle one)

with you

 

 

 

 

 

 

 

(circle one)

 

 

 

 

 

 

 

 

 

Self

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

 

 

 

 

 

 

 

 

 

 

M F

 

Y

N

Y

N

If there are others living in your home, add to a separate sheet of paper.

(3) Does anyone get money from any other source? c Yes c No (if yes, complete below, attach proof.)

Some examples are:

• Social Security

• Unemployment Compensation

• Veterans benefits

 

• Child support

• Workers’ Compensation

• Loans/gifts

Name of person who got

Source of

How often

Amount of

Amount

Will this

other money

other money

 

paid

each payment

this month

income continue

 

 

 

 

 

 

 

 

 

 

 

 

$

$

c Yes

c No*

 

 

 

 

$

$

c Yes

c No*

 

 

 

 

$

$

c Yes

c No*

* If income will change, give the new amount. What is the reason for the change and when it will change?

Turn over and answer all questions. Be sure to sign and date on the back.

DHS 0852 (10/18) Page 3, Can use prior version

(4) Does anyone work? c Yes

c No (If yes, complete below.)

 

List each job for each person who works. Attach proof of the income received in the

report month. (Report month is listed at top of page 3.)

 

 

 

 

 

If self-employed, check here c

Job #1

Job #2

Job #3

 

 

 

 

Person working:

 

 

 

Employer’s name and phone number:

 

 

 

 

 

 

 

Job title:

 

 

 

Hourly pay:

$

$

$

If you are not paid by the hour, explain your

income here:

 

 

Hours (per week):

 

 

 

How often paid (weekly, monthly):

 

 

 

Pay dates:

 

 

 

Tips per week:

 

 

 

Draws, overtime pay, bonuses or

$

$

$

commissions:

 

 

 

Will this income continue?

c Yes c No*

c Yes c No*

c Yes c No*

 

 

 

 

*If income will change, give the reason for

the change here:

 

 

 

 

 

 

New amount:

$

$

$

Date of the change:

 

 

 

(5) Does anyone in your household work as a volunteer?

Name of volunteer:

Hours per week:

(6)Paying child support: If anyone living with you is court-ordered to pay child support, has the

court-order changed? c Yes c No

If yes, amount per month $_________________

Read and sign: The information I give on this form is true and complete. I have read all four pages of this form and understand it. I agree to the conditions on page 2.

Signature of person completing this form:

Phone:

Date:

Original: Case record

DHS 0852 (10/18) Page 4, Can use prior version

File Breakdown

Fact Name Details
Program The Interim Change Report form is used specifically for the Supplemental Nutrition Assistance Program (SNAP).
Submission Deadline Form submission must occur between the 1st and 10th day of the month to avoid delays in benefits.
Eligibility Verification This form helps verify ongoing eligibility for food benefits.
Household Income All household income must be reported, including both earned and unearned sources.
Discrimination Policy The Department of Human Services (DHS) does not discriminate based on age, race, gender, and other factors.
State Law This form is governed by Oregon state law, which includes protections against discrimination based on sexual orientation and political beliefs.
Penalties There are penalties for providing false information, which can include loss of benefits for varying durations.
Contact Information If assistance is needed, applicants can call the number provided at the top of the form.

Guide to Using Interim Change Report

Completing the Interim Change Report form is an important step to ensure that you remain eligible for benefits. You will need to provide accurate and detailed information about your current household situation, including income and living arrangements. Be sure to return the form within the specified timelines to avoid any disruptions to your benefits.

  1. Gather necessary information: Collect documents and information about your household, including the names, relationships, and incomes of all individuals living with you.
  2. Fill out basic details: In the designated sections, enter the Program, Branch, Case number, Case name, and Worker ID.
  3. Complete contact information: Provide your home address, mailing address, and phone number. Include your message number, if applicable.
  4. Housing information: Indicate whether you pay for housing. If yes, specify if you rent or have a mortgage, and provide details about your monthly payment, property tax, and homeowners’ insurance.
  5. Heating source: Identify how your home is heated and whether the heating cost is included in your rent.
  6. Utilities: Check all utilities that you pay for each month.
  7. List household members: For each person living with you, provide their name, relationship to you, sex, date of birth, and indicate if they want SNAP benefits and prepare meals.
  8. Income from other sources: Specify if anyone in the household receives income from other sources. If yes, give details about the source, amount, frequency, and whether the income will continue.
  9. Employment information: If anyone works, list their jobs, providing the employer’s name, job title, hourly pay, and any additional income details like tips or bonuses.
  10. Child support: If applicable, indicate if anyone is court-ordered to pay child support and if the amount has changed.
  11. Affirmation: Sign and date the form. Ensure you affirm the information is true and complete.

After you have filled out the form carefully, review it to ensure all information is complete and accurate. Submit the form by the required deadline to prevent any potential delays in your benefits. Consider storing a copy for your records.

Get Answers on Interim Change Report

What is the purpose of the Interim Change Report form?

The Interim Change Report form is used to ensure that you remain eligible for Supplemental Nutrition Assistance Program (SNAP) benefits. By reporting any changes in your household income or circumstances, you help the Department of Human Services assess your eligibility.

When should I submit the Interim Change Report form?

You must return this form between the 1st and the 10th day of the month. Failing to submit the form by the 10th can lead to delays or interruptions in your benefits. Ensure that your form is complete and accurately filled out to avoid any issues.

What happens if I submit the form late?

If you submit the form after the 10th day of the month, or if it is incomplete, your SNAP benefits may be delayed or stopped. Timely submission is crucial for uninterrupted assistance.

What information do I need to provide on the form?

Provide information about all household members living with you, including:

  • Income from all sources
  • Housing costs
  • Utilities paid
  • Employment details, if applicable

If additional space is needed, attach a separate sheet of paper and be sure to include proof of reported changes.

What should I do if I have questions while filling out the form?

If questions arise during the process, call the number listed at the top of the form. Assistance is available, and you can call collect if needed.

What are the consequences of providing false information?

Providing false information may lead to severe consequences, including loss of benefits, fines, or criminal charges. Details regarding these penalties are outlined in the form to ensure you understand the serious implications of misreporting.

Can I get help with the form if I have a disability?

Yes, auxiliary aids and services are available upon request for individuals with disabilities. Don’t hesitate to ask for assistance to ensure you can complete the form accurately.

Is this form an application for benefits?

No, the Interim Change Report is not an application for SNAP benefits. It is a way to report changes in your circumstances to maintain ongoing eligibility for assistance.

Common mistakes

When individuals fill out the Interim Change Report form for the Supplemental Nutrition Assistance Program (SNAP), several common mistakes can lead to delays or issues with their benefits. Understanding these pitfalls is crucial for ensuring a smooth process.

One significant error involves missing deadlines. The form must be returned between the 1st and the 10th day of the specified month. Failing to submit the form within this timeframe can result in a disruption of benefits, which can strongly affect recipients’ access to food assistance.

Another frequent mistake is the failure to provide complete information. Applicants must answer all questions regarding themselves and everyone living in their household. Omitting details about other household members or their income can lead to an incomplete application, resulting in delays or denial of benefits.

Additionally, people often neglect to attach necessary documentation to support their reported income or other changes. The form specifies that proof of income must be included. Without this evidence, the application may be deemed insufficient, further complicating the process for benefit continuation.

Many applicants also make the error of not specifying their housing costs correctly. It is essential to report the exact amount paid for housing, whether it be rent or mortgage, including any separate homeowners’ insurance and property taxes. Inaccurate reporting of these costs could affect the calculation of benefits.

Some individuals omit reporting all sources of income. SNAP requires an account of both earned and unearned income from every household member. Failing to disclose income from sources such as Social Security, unemployment benefits, or child support contributes to incomplete applications and can cause complications for applicants.

Improperly filling out the employment information section is also common. Applicants must provide details for each job held by household members, including the employer’s name and contact information. If employment is misreported or details are left blank, this could cause significant discrepancies in benefits calculations.

People also tend to skip the signature requirement. The form must be signed and dated to confirm that the information provided is accurate. Neglecting this step can render the submission invalid, causing the application not to be processed.

Additionally, some individuals misunderstand how to report changes. If there are changes in income or living arrangements, these must be marked clearly. Miscommunication of changes can lead to confusion about eligibility and benefits.

Finally, some applicants fail to contact their caseworker for assistance when needed. The form encourages applicants to reach out if they have questions. Ignoring this option may result in misunderstandings about the filling process, potentially compromising the accuracy of submitted information.

Recognizing these mistakes can help ensure that applicants navigate the Interim Change Report form process more effectively. By taking care to provide accurate and complete information, individuals can work to prevent interruptions in their SNAP benefits.

Documents used along the form

The Interim Change Report form is an essential document used in the Supplemental Nutrition Assistance Program (SNAP). It helps determine if recipients still qualify for benefits. Along with this form, several other documents are commonly used to manage SNAP cases effectively. Below is a list of these associated forms and their purposes.

  • Application for Benefits: This form initiates a request for SNAP benefits. It gathers essential information from the applicant about household income and expenses to determine eligibility.
  • Verification Documents: These may include wage stubs, bank statements, or proof of residency. They provide the necessary evidence to support claims made on the Interim Change Report.
  • Intent to Change Form: This is used by applicants to notify the agency of any upcoming changes in their circumstances, such as employment status or household size, before they submit the Interim Change Report.
  • Periodic Report Form: Required for households that receive benefits for a longer period. This form is submitted at set intervals to confirm continuing eligibility and report any changes in income or living arrangements.
  • Reassessment Form: Used for renewing benefits after the initial eligibility period. It requires updated information on household income, expenses, and changes in circumstances.
  • Conflict Resolution Form: This is used when an applicant disagrees with an agency decision regarding their benefits. It allows individuals to appeal decisions and seek clarification or changes.
  • Authorization for Release of Information: This document allows the agency to obtain necessary details about the applicant from other sources such as employers or financial institutions for verification purposes.
  • Client Choice Document: This form lists available SNAP benefits and allows clients to express their preferences. It helps in ensuring that participants receive the types of benefits that best meet their needs.

Each of these forms plays a vital role in the SNAP process, ensuring that benefits are distributed fairly and that recipients receive the support they need. It's important to complete and submit these documents accurately and promptly to avoid interruptions in benefits. Always check with your local agency for the specific forms required in your area.

Similar forms

  • Change of Circumstances Form: Similar to the Interim Change Report, this document is used to update the agency about any changes in a household's situation that may affect benefits. Both require detailed information about income, household members, and any changes in circumstances.
  • Annual Review Form: This form is also used to determine ongoing eligibility for benefits. Like the Interim Change Report, it collects information about household income and members, ensuring that the agency has up-to-date data on the applicant's situation.
  • Benefit Eligibility Verification Form: This document serves to verify ongoing eligibility for programs. Similar to the Interim Change Report, it requires proof of income and details about all members living in the household.
  • New Application for Benefits: This document is used to apply for benefits for the first time or to add a new household member. Both forms seek personal details and information about income but differ in purpose, as the application sets up a new case while the Interim Change Report updates an existing one.
  • Income Statement Form: This form is used to report income, similar in purpose to the sections within the Interim Change Report that asks for income details. Both require accurate reporting and proof of all income sources in the household.
  • Household Composition Form: Used to list all individuals living in a household, this form is similar to the Interim Change Report since it also requires information about each member’s relationship to the primary applicant and their income contributions.

Dos and Don'ts

When filling out the Interim Change Report form for Supplemental Nutrition Assistance Program (SNAP), there are several important actions to consider. Here’s a list of things you should and shouldn't do:

  • Do: Submit the form between the 1st and 10th day of the month to avoid delays in benefits.
  • Do: Answer all questions for yourself and everyone living with you.
  • Do: Attach additional sheets if more space is needed for responses.
  • Do: Provide proof for any information you report.
  • Do: Contact the provided phone number if you need assistance with the form.
  • Don't: Return the form after the 10th of the month.
  • Don't: Submit an incomplete form, as it may delay your benefits.
  • Don't: Forget to sign and date the back of the form.
  • Don't: Provide false information or hide details, as this can lead to severe penalties.

Misconceptions

  • Misconception 1: The Interim Change Report form is an application for benefits.
  • This form is not an application but rather a document that verifies eligibility for ongoing assistance. It’s crucial to understand that submitting this form does not equate to applying for new benefits.

  • Misconception 2: Only primary applicants need to fill out the form.
  • All household members’ information must be included. Every individual living with the applicant will affect the eligibility and benefits amount.

  • Misconception 3: There is no deadline for submitting the form.
  • The form must be submitted between the 1st and 10th of the month. Late submissions can lead to delays or cessation of benefits.

  • Misconception 4: Incomplete forms will be automatically processed.
  • An incomplete form may cause significant delays in benefits, if not outright cancellation. It is essential to answer all questions fully.

  • Misconception 5: Income needs to be reported only if it exceeds a certain threshold.
  • Every form of income, whether earned or unearned, must be reported. This includes small amounts that may seem insignificant but can impact eligibility.

  • Misconception 6: Proof of income isn’t necessary if you report your earnings accurately.
  • Misconception 7: You can submit the form at any time during the month.
  • This is incorrect. The form must be returned specifically between the 1st and 10th to avoid interruptions in benefits.

  • Misconception 8: There are no penalties for failing to report changes.
  • Failing to accurately report changes can lead to serious repercussions, including the loss of benefits or legal consequences. Compliance is critical for maintaining assistance.

Key takeaways

Filling out the Interim Change Report form accurately and completely is essential for maintaining your benefits. Here are seven key takeaways to guide you through the process:

  • Submit on Time: Make sure to return the form between the 1st and 10th of the reporting month to avoid delays in receiving benefits.
  • Complete All Sections: Answer all questions for everyone in your household. This includes providing details about income and living arrangements.
  • Attach Necessary Documentation: Include proof of any income or changes you report. This could be pay stubs, benefit letters, or bank statements.
  • Sign and Date: Don’t forget to sign and date the form on the back. An unsigned form may be considered invalid.
  • Avoid Penalties: Be aware that giving false information or hiding details can lead to loss of benefits and legal consequences.
  • Check for Help: If you're uncertain about any part of the form, reach out for assistance. There is a number at the top you can call, and collect calls may be accepted.
  • Be Mindful of Changes: If any changes occur after submitting the report, such as a job loss or income change, inform your caseworker promptly to ensure your benefits reflect your current situation.

Keeping these key points in mind will help you navigate the Interim Change Report form with confidence and ease.”