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The Interim Change Report form plays a crucial role for individuals and families participating in the Supplemental Nutrition Assistance Program (SNAP). Understanding the form's components is essential to ensure that recipients do not experience any interruptions in their benefits. Specifically designed to collect information about changes in household circumstances, this form prompts users to provide details about their living arrangements, sources of income, and any other pertinent financial data. It must be completed thoroughly for everyone residing in the household, featuring sections that inquire about employment status, monthly expenses, and child support arrangements. The urgency of submitting this form by the designated timeline cannot be overstated; it must be returned between the 1st and 10th day of the reporting month to avoid potential delays in benefits. Each question must be answered accurately, and supporting documentation should be attached when necessary. Recipients should also be aware of the anti-discrimination policy and the significant consequences that can arise from providing false information. Adhering to the instructions on this form can make the difference between receiving essential food benefits or facing interruptions during uncertain times.

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: DHS.info@state.or.us

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
Get Interim Change Report PDF Form

Form Characteristics

Fact Name Fact Details
Program The form is part of the Supplemental Nutrition Assistance Program (SNAP).
Submission Deadline It must be returned between the 1st and 10th of the designated month to avoid delays in benefits.
Eligibility Confirmation This form is used to confirm ongoing eligibility for food benefits.
Information Required Participants must report income and provide information for all household members.
Discrimination Policy DHS and OHA will not discriminate based on age, race, gender, disability, or other protected categories.
Consequences for Misreporting Penalties may include loss of benefits and possible legal action for false reporting or fraud.
Governing Law This form is governed by state laws in Oregon, specifically pertaining to SNAP regulations.

Guidelines on Utilizing Interim Change Report

Upon completion of the Interim Change Report form, submit it promptly to help ensure continuity of your Supplemental Nutrition Assistance Program (SNAP) benefits. Be sure to provide accurate information as this will directly impact your benefits.

  1. Locate the form titled Interim Change Report.
  2. Fill out the Program, Branch, Case number, Case name, and Worker ID at the top of the form.
  3. Indicate the month for which you are reporting in the space provided.
  4. Provide your home address and mailing address, including the relevant city, state, and ZIP codes.
  5. Enter a phone number and a message number, if applicable.
  6. Answer the question about housing costs. If applicable, specify whether you rent or have a mortgage and complete the payment details.
  7. Indicate how your home is heated and whether heating expenses are included in your rent.
  8. List all utilities that you pay, including electricity, phone, water/sewer, and others as applicable.
  9. Identify all individuals living in your home, providing their relationship to you, sex, date of birth, and whether they wish to receive SNAP benefits.
  10. Answer whether anyone in the household receives other forms of income. If yes, complete the details and attach proof.
  11. If anyone works, specify their job information. Be sure to attach proof of income for the report month.
  12. If applicable, provide details about volunteer work by household members.
  13. Report any changes regarding child support obligations, sharing the new amount if applicable.
  14. Sign and date the form, confirming that the information provided is accurate and complete.

What You Should Know About This Form

What is the purpose of the Interim Change Report form?

The Interim Change Report form is essential for individuals receiving benefits through the Supplemental Nutrition Assistance Program (SNAP). It is used to report any changes in your situation that may affect your eligibility for food assistance. By filling out this form, you help ensure that you continue to receive your benefits without interruption. It is crucial to return this form promptly between the 1st and the 10th of the designated month to avoid delays.

Who needs to fill out this form?

This form must be completed for everyone living in your household who receives SNAP benefits. You should answer all questions about yourself and all other individuals residing with you. This includes disclosing income from various sources, whether earned or unearned. Ensuring that the information is complete and accurate is vital for the continuation of benefits.

What happens if I do not return the form on time?

If you do not return the Interim Change Report form by the last day of the month as required, there may be consequences. Your benefits could stop, and you may face delays in receiving assistance while you work to rectify the situation. To avoid any loss of benefits, it’s important to make sure the form is submitted during the specified time frame.

What types of information should I include in the form?

When completing the form, you need to include various types of information. This includes your income from all sources, housing costs, details about who lives with you, and any significant changes in your circumstances. If additional space is needed, you can attach extra sheets. Providing proof of the income and changes reported is also necessary to support the information you submit.

Can I get assistance if I have questions while filling out the form?

Yes, if you have questions or need help while completing the Interim Change Report form, you can call the number listed at the top of the form. Assistance is available, and you may also call collect if necessary. Don’t hesitate to reach out for help; it’s important to ensure the form is filled out correctly to avoid disruptions in your benefits.

Common mistakes

Filling out the Interim Change Report form correctly is vital for maintaining your Supplemental Nutrition Assistance Program (SNAP) benefits. However, many people make mistakes that can lead to delays or even loss of benefits. Here are nine common errors to avoid when completing this form.

One mistake is missing the crucial deadline for submission. It is mandatory to return this form between the 1st and 10th of the reporting month. Submitting it late can complicate your benefits, leading to a potential stoppage. Always mark the deadline clearly on your calendar.

Another common issue arises from not providing complete information. Some individuals skip questions or fail to include details about everyone living in the household. Each person should be listed accurately along with their income sources. If a question seems unclear, it's better to ask for help than risk leaving it unanswered.

Omitting proof of income is another significant error. When reporting certain incomes—such as unemployment benefits or child support—proof must accompany your form. This could include pay stubs, bank statements, or court orders. Without this documentation, your benefits may be delayed.

Many people also forget to sign and date the form. Neglecting to do this can render the form invalid, making it necessary to start over. Ensure you check both sides of the form for your signature and date before submitting it.

In some cases, applicants misunderstand the requirements for household income. All sources of income must be reported accurately, including both earned and unearned income for all household members. Providing an incomplete picture can impact your eligibility and the amount of your benefits.

People often fail to report changes in their circumstances timely. If there are changes in income, household composition, or living situation, these must be documented immediately. The SNAP program requires that you report these changes immediately to avoid complications.

Confusing volunteer work with paid work is another error. If someone in your household is a volunteer, be sure it is clearly distinguished from paid employment on the form. Mislabeling this can affect the benefits calculated.

Additionally, some applicants do not use the sheet provided for extra information. If there isn’t enough space to answer all questions, attaching a blank sheet of paper is acceptable. Make sure to label any additional sheets clearly so that the information doesn’t get overlooked.

Lastly, forgetting to double-check the contact information can cause logistical issues. Ensure that your phone number and address are current and correct. If any correspondence needs to go out, having the right details ensures you'll receive it in a timely manner.

By avoiding these common pitfalls, you can help ensure that your Interim Change Report is processed smoothly, securing your access to necessary benefits.

Documents used along the form

The Interim Change Report form is essential for anyone enrolled in the Supplemental Nutrition Assistance Program (SNAP). Alongside this form, several other documents may be necessary for a complete benefit review process. Below is a list of these commonly used forms.

  • Application for Benefits - This document initiates the process to determine eligibility for SNAP benefits. It collects personal, household, and income information to establish initial qualification.
  • Eligibility Verification Form - Used to confirm the eligibility of applicants or beneficiaries. This form often requires proof of income, residency, and household composition.
  • Income Report Form - This form details all sources of income for household members. It ensures that the agency has up-to-date information on eligibility and benefit amounts.
  • Verification Documents - While not a specific form, these documents may include pay stubs, bank statements, or any official paperwork that confirms the information provided on the application and change report.
  • Notice of Action - This document informs beneficiaries of any changes to their SNAP benefits. It outlines reasons for changes and potential next steps if further action is needed.
  • Renewal Form - Typically submitted annually, this form helps renew SNAP benefits. It requires updated household income, expenses, and personal information to continue receiving assistance.
  • Feedback and Complaint Form - This form allows individuals to file complaints regarding their SNAP experience or express concerns about service issues. Feedback is vital for improving the program.

Familiarizing yourself with these forms can streamline the application and benefit management process, ensuring continuity in assistance. Each document plays a crucial role in maintaining accurate and fair access to nutrition resources.

Similar forms

  • Eligibility Review Form: This document also verifies the ongoing eligibility of a household for SNAP benefits. Similar to the Interim Change Report, it requires comprehensive responses regarding household income and living conditions, ensuring that recipients remain qualified for assistance.
  • Annual Recertification Form: Like the Interim Change Report, this form is submitted on a set schedule to confirm continued eligibility for SNAP. It requires information about all household members and their financial situation over the past year to assess the need for assistance.
  • Change of Address Form: This form, much like the Interim Change Report, requires beneficiaries to report significant changes that could affect their SNAP benefits. Accurate information ensures correct processing and avoids delays in benefits.
  • Income Statement: This document requests detailed income information from all household members, similar to what is required on the Interim Change Report. Verification of income sources is crucial for determining ongoing eligibility and benefit amounts.
  • Household Composition Form: This form captures vital information about everyone living in a household, akin to the Interim Change Report. It ensures all relevant parties are accounted for when assessing eligibility for food assistance programs.
  • Verification of Employment Form: Also similar to the Interim Change Report, this document collects employment data from household members. This information helps determine eligibility based on income derived from employment and helps assess overall need for support.

Dos and Don'ts

When filling out the Interim Change Report form for the Supplemental Nutrition Assistance Program (SNAP), it’s essential to keep a few key points in mind to ensure a smooth and efficient process. Below is a list of things you should do and things you should avoid:

  • Do: Answer all questions completely for yourself and everyone living in your household.
  • Do: Attach any necessary proof of income or changes to your household.
  • Do: Submit the form between the 1st and 10th day of the reporting period to prevent delays.
  • Do: Contact your caseworker if you have questions about the form.
  • Do: Sign and date the form on the back to confirm accuracy and understanding.
  • Don't: Wait until after the 10th of the month to submit the form, as this may delay your benefits.
  • Don't: Provide incomplete information or leave any sections blank.
  • Don't: Fail to attach additional sheets if you need more room to provide details.
  • Don't: Forget to report all household members' income from every source.
  • Don't: Use the form as an application; it’s solely for reporting changes in circumstances.

By following these guidelines, you’ll increase the chances of your form being processed quickly and help maintain your eligibility for benefits. Remember, being thorough and timely is key!

Misconceptions

  • Misconception 1: The Interim Change Report form is the same as a new application.

    • This form is specifically for reporting changes in your circumstances while you are already receiving benefits. It is not a new application for benefits.

  • Misconception 2: You can submit the form any time during the month.

    • The form must be submitted between the 1st and 10th day of the month to avoid delays in benefits. Submitting it after this period may result in a halt of your benefits.

  • Misconception 3: Only income changes need to be reported.

    • The form requires you to report all changes in your household, including income, living situation, and household composition.

  • Misconception 4: Providing false information on this form has no severe consequences.

    • Providing false information can result in severe penalties, including fines, imprisonment, and loss of benefits. Honesty is crucial.

  • Misconception 5: You do not need to provide proof of reported changes.
  • Misconception 6: You do not need to provide information about everyone living with you.

    • The form must be filled out for all members of your household, including their income and living situations. All individuals must be recorded for accurate processing.

  • Misconception 7: The form can be completed and submitted without understanding its contents.

    • It is important to read and understand the entire form before completing it. There are consequences if errors or omissions occur, affecting benefit eligibility.

  • Misconception 8: Your eligibility for SNAP benefits does not depend on the accuracy of the information provided.

    • Eligibility directly correlates with the accuracy of the information on the Interim Change Report. Misrepresentation may lead to benefits being adjusted or terminated.

Key takeaways

When you're filling out the Interim Change Report form for the Supplemental Nutrition Assistance Program (SNAP), consider the following key takeaways to ensure a smooth process:

  • Timely Submission is Crucial: Make sure to submit the form between the 1st and 10th day of the month. Missing this window could mean a delay or a complete stop to your benefits.
  • Complete All Sections: Answer every question thoroughly for yourself and everyone living with you. If you run out of space, it’s okay to attach an additional sheet. Ensuring that all income sources are reported is essential.
  • Proof Matters: Attach necessary documentation that supports the information you provided. This helps verify your claims and can prevent delays in processing your benefits.
  • Don’t Ignore the Consequences: Be aware of the rules and penalties outlined. Misreporting information or failing to comply could lead to a suspension of benefits or even legal penalties.

By keeping these points in mind, you enhance your chances of receiving the maximum benefit without interruption. Filling out this form may seem daunting, but you're not alone—help is available if you need it.

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