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