MISSOURI DEPARTMENT OF SOCIAL SERVICES
                                   FAMILY SUPPORT DIVISION                                                                                                 USE THIS FORM ONLY TO REPORT CHANGES
                                   CHANGE REPORT                                                                                      RETURN COMPLETED FORM TO YOUR LOCAL FSD OFFICE
                                CASEWORKER                                                                                     TELEPHONE NUMBER                                           DATE
                  FROM                                                                                                                              -   -    
                                COUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
                                      
                                      
                                NAME
                     TO               
                                ADDRESS (STREET)
                                      
                                CITY                                                                  STATE                    ZIP CODE
                                                                                                                                     
                                CASE NAME                                                                                                                            DCN
                     RE                                                                                                                                                                           
                If your household circumstances change in any of the ways listed below, Federal law requires you to report the changes to your FSD county
                office within ten (10) days.  You may use this form to report the changes or you may write, phone or visit the FSD office to report the changes.
                If you have any questions, you may call your worker at        -       -        or you may call the
                Food Stamp Hotline toll free at 800-392-1261.
                A.    NEW HOUSEHOLD MEMBERS List income and resources (savings, vehicles, etc.) in C, D & E below.
                                             NAME                                       RELATIONSHIP                 BIRTHDATE              SOCIAL SECURITY NO.                  DATE MOVED IN             DISABLED? Y/N
                                                                                                                                                   -  -                                   
                                                                                                                                                                                                                     
                                                                                                                                                   -  -                                   
                                                                                                                                                                                                                     
                    SOCIAL SECURITY NUMBERS:
                    You must provide the Social Security Number (SSN) of all persons applying for or receiving Food Stamps as a condition of eligibility.
                    The SSN will be used to determine eligibility and level of benefits, verify information, prevent duplicate issuances, and to facilitate
                    mass changes in Federal benefits. (FS Act of 1977 & Public Law 97-98).
                B.    HOUSEHOLD MEMBERS NO LONGER LIVING WITH YOU
                                                NAME                                             DATE LEFT                                              NAME                                               DATE LEFT
                                                                                                                                                                                                                 
                                                                                                                                                                                                                 
                C.    CHANGE IN INCOME (ATTACH VERIFICATION FOR TEMPORARY ASSISTANCE AND FOOD STAMPS)
                      EARNED INCOME: (Earned income includes wages, salaries and income from self employment)
                      FOR BOTH TEMPORARY ASSISTANCE AND FOOD STAMPS, YOU MUST REPORT THE FOLLOWING CHANGES.
                       • Any changes in the source of any type of earned income for any household member.
                       • Any changes in the base rate of pay for any employed household member.
                       • Any permanent change in the number of hours worked that is expected to continue for any employed household member.
                       • If you become employed or if you lose your job.
                      UNEARNED INCOME: (Unearned income includes Social Security, Supplemental Security Income-SSI, veterans benefits, child support, alimony, etc.)
                      FOR FOOD STAMPS, YOU MUST REPORT:
                       • Any changes of more than $25 in unearned income.
                      FOR TEMPORARY ASSISTANCE, YOU MUST REPORT:
                       • Any changes in unearned income (You do not have to report your Temporary Assistance check)
                                         NAME                                     SOURCE OF INCOME                              DID INCOME                     NEW AMOUNT               RATE OF PAY            NO. HOURS
                                                                                  
                                                                                                                             START     STOP   OTHER
                                                                                                                                                                                                                    
                                                                                                                       DATE                 CHANGE
                                                                                  
                                                                                                                             START     STOP   OTHER
                                                                                                                                                                                                                    
                                                                                                                       DATE                   CHANGE
                 D.  CHANGE OF VEHICLES OR CAR (INCLUDES BOATS, TRAILERS, RECREATION VEHICLES, SNOWMOBILES, ETC.)
                                              MAKE                  MODEL                 YR               OWNER                  LICENSED Y/N              VALUE              DEBT            HOW IS VEHICLE USED
                BOUGHT   Y  N                                                                                                                                                                                  
                SOLD          Y   N                                                                                                                                                
                BOUGHT   Y  N                                                                                                                                                                                  
                SOLD          Y   N                                                                                                                                                
                MO 886-0417 (4-99)/E 04-2004                                                                                                                                                                  IM-145 (11/2021)
                     E.    INCREASE IN CASH SAVINGS, STOCKS, BONDS, CHECKING ACCOUNTS, ETC.
                     HOW MUCH DOES YOUR HOUSEHOLD NOW HAVE IN CASH/SAVINGS? (FOR FOOD STAMPS YOU MUST REPORT WHEN YOUR RESOURCES EXCEED $2,000.00) (FOR TEMPORARY 
                     ASSISTANCE YOU MUST REPORT ALL CHANGES IN RESOURCES.)
                            
                     F.    IF YOU HAVE MOVED
                     WHEN?                                                                                                                                                                      TELEPHONE NUMBER WHERE YOU CAN BE REACHED
                                                                                                                                                                                                                                          -   -    
                     NEW MAILING ADDRESS (STREET, CITY, STATE, ZIP CODE)
                            
                     HAVE YOU MOVED IN WITH SOMEONE ELSE?                                                                 YES                NO                 ARE YOU A BOARDER?                                                            YES                    NO
                     IF YES, PLEASE LIST HOUSEHOLD MEMBERS AT THIS ADDRESS
                            
                     G.    CHANGE IN RENT, MORTGAGE, OR UTILITIES (GAS, ELECTRICITY, OIL, ETC.) FOOD STAMPS ONLY
                     If you have moved, place a check (X) mark in the appropriate boxes for expenses you have at the new residence.                                                                                                                                           N/A
                            Rent                                           Amt $                                     Who pays?                                                                                                                                                   Water
                            Mortgage                                       Amt $                                     Who pays?                                                                                                                                                   Sewer
                            Real Estate Taxes                              Amt $                                     Who pays?                                                                                                                                                   Trash
                            Property Insurance                             Amt $                                     Who pays?                        
                            Electric                                       Used for:                                 Heating                                    Cooling                               Other                 
                            Gas/Propane                                                                              Heating                                    Cooling                               Other                 
                     H.    CHANGE IN DEPENDENT CARE COSTS (ATTACH VERIFICATION) OPTIONAL IF FOOD STAMPS ONLY
                               PROVIDER’S NAME                                       TELEPHONE NUMBER                                          NEW AMOUNT PAID                                       WHO PAYS EXPENSE                                            HOW OFTEN  PAID
                                                                                         -   -                                                                                                                                                                               
                                                                                         -   -                                                                                                                                                                               
                     I.    CHILD SUPPORT EXPENSE: List any legally binding child support paid to NON-HOUSEHOLD members (includes current
                             payments, arrearages, and health insurance).
                                                                     DEPENDENT’S NAME                                                                                     AMOUNT PAID                                                         HOW OFTEN PAID
                       1.                                                                                                                                                                                                                                     
                       2.                                                                                                                                                                                                                                     
                       3.                                                                                                                                                                                                                                     
                     J.    FOR TEMPORARY ASSISTANCE, PLEASE PROVIDE ANY INFORMATION THAT HAS CHANGED OR WAS NOT
                               PREVIOUSLY REPORTED ON THE ABSENT PARENT.
                            
                     K.    OTHER - PLEASE REPORT ANY OTHER CHANGES HERE:  Examples:  Change in medical insurance or coverage, a marriage or 
                               divorce, ownership of property, etc. (Optional if Food Stamps only)
                            
                     L.    WILL THE CHANGE(S) BE FOR MORE THAN ONE MONTH?                                                                                                YES                    NO
                     IF YOU PURPOSELY HOLD BACK INFORMATION ABOUT CHANGES IN YOUR HOUSEHOLD, YOU WILL OWE US THE VALUE OF EXTRA BENEFITS YOU RECEIVE AS A
                     RESULT.  YOU MAY ALSO BE BARRED FROM THE FOOD STAMP PROGRAM FOR 1 YEAR, 2 YEARS, OR PERMANENTLY AND BE FINED, AND/OR IMPRISONED.
                     PENALTY WARNING:  Any information provided on this form is subject to verification by federal, state, and local officials.  If any is inaccurate, you may be denied food stamp benefits
                     and/or be subject to criminal prosecution for knowingly providing false information.
                     13 CSR 40-2.190 provides for recovery of benefits when it is determined someone has received benefits they are not entitled to.
                     7 USC 2024(b)(c) and (h).  Anyone who knowingly uses, transfers, acquires, alters or possesses coupons, or access devices in any manner contrary to the Food Stamp Act is subject to
                     fine and imprisonment.  Upon conviction, punishments include a fine of $250,000 and/or imprisonment for 20 years if the value of the coupons or access devices is $5,000 or more.  If the
                     value is less than $5,000 but greater than $100, punishments include a fine of $10,000 and/or imprisonment for 5 years.  If the value is less than $100, punishments include a fine of
                     $1,000 and/or imprisonment for 1 year.  Anyone who presents for payment or redemption coupons which have been illegally received, transferred, or used is subject to a fine of $20,000
                     and/or imprisonment for 5 years if the value of the coupons is $100 or more.  If the value is less than $100, punishments include a fine of $1,000 and/or imprisonment for 1 year.  Anyone
                     convicted of felony offenses relating to the above transactions is also subject to having all real and personal property used in such transactions forfeited to the United States.
                     7 USC 2015(b)(1).  Anyone convicted in a federal, state or local court of trading benefits for controlled substances, illegal drugs or certain drugs for which a doctor’s prescription is
                     required, shall be barred from the Food Stamp Program for 2 years for the first offense and permanently for the second offense.  Anyone convicted of trading benefits for firearms,
                     ammunition, or explosives is barred permanently from the Food Stamp Program for the first offense.
                     7 USC 2015(b)(1)(iii)(IV) and 2015 (j).  Anyone convicted of trafficking in food stamp benefits of $500.00 or more shall be permanently disqualified from the Food Stamp Program for the
                     first offense.  Anyone found by a state agency to have made or convicted in a federal or state court of having made fraudulent statements about identity or residence in order to receive
                     multiple food stamp benefits simultaneously shall be ineligible to participate in the Food Stamp Program for ten (10) years beginning with the date of such agency determination or such
                     conviction in a federal or state court.
                     I understand the penalty for hiding or giving false information.  I also understand I will owe the value of any extra benefits I receive because I do not fully report changes in my household.
                     My signature below certifies under the penalty of perjury that all declarations made on this change report are true, accurate, and complete.
                     CLIENT SIGNATURE                                                                                                                          TELEPHONE NUMBER                                                                             DATE
                                                                                                                                                                                                 -   -                                                             
                     MO 886-0417 (4-99)/E 04-2004                                                                                                                                                                                                                                                  IM-145 (11/2021)