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Revised 9/2022 Supplemental Nutrition Assistance Program (SNAP) CHANGE REPORT FORM PLEASE FILL OUT SECTION IN THE CHART BELOW ATTENTION: This form can be used to report mandatory or voluntary changes in your household circumstances. The only mandatory changes that households are required to report is: 1. If the household, at time of application or recertification, was certified at or below the 130% poverty gross income limit based on household family size, and the new monthly gross income exceeds. a. If the household’s gross income was greater at time of application or recertification the household does not have to report the increase in income. See income chart below. 2. If any member of the household received a single winning of $4,250 or greater from lottery or gambling. ALL OTHER CHANGES ARE OPTIONAL AND VOLUNTARY, however, once this form is received by the office, the office will act on the changes reported. Households are encouraged to report any changes that the household believes would increase the household’s SNAP benefits. Number of persons you get SNAP for (to include disqualified member) 130% Poverty Gross Income Limit 1 $1,473 2 $1,984 3 $2,495 4 $3,007 5 $3,518 6 $4,029 7 $4,541 8 $5,052 9 $5,564 10 $6,076 Each additional person add: $512 Date: _______________________________ Case Name: __________________________________ Case Number:_________________________________ Contact No: __________________________________ Email Address: _______________________________ Mailing Address:_______________________________ _____________________________________ SI USTED NO ENTIENDE ESTE FORMULARIO O NECESITAS AYUDA, COMUNIQUESE CON SU OFICINA LOCAL DE CERTIFICACION. DISTRICT OFFICES ARE LOCATED AT ST. THOMAS -1303 Hospital Ground, STE.1 VI, 00802-6722 Phone No.: 340-774-2399 - Fax No: 340-777-5449 Email: certoffice.stt@dhs.vi.gov ST. JOHN- Human Services Multi-Purpose Bld., Cruz Bay, VI 00830 Phone No.: 340-776-6334; 340-776-6335 Email: certoffice.stt@dhs.vi.gov ST. CROIX- 4102 Mars Hill, Frederiksted, VI 00840-3376 Phone No.: 340-772-7100 - Fax No.: 340-772-9591 Email: certoffice.stx@dhs.vi.gov Change Report – Page 2 Complete the section(s) that pertains to the change(s) your household is reporting and attach the supporting documents, where necessary. CHANGES IN HOUSEHOLD COMPOSITION Name of Left Entered Elderly or disabled household member household 1. Yes No 2. Yes No 3. Yes No CHANGES IN HOUSEHOLD’S INCOME OR SOURCE OF INCOME Name of household member Source of income New Amount 1. $ 2 $ 3. $ NEW SOCIAL SECURITY NUMBER Name Social Security number 1. 2. 3. CHANGES IN RENT OR MORTGAGE If the household moved, what is new address City State Zip Code If you do not have a street address, tell us how to get to your home Telephone number where you can be reached Rent or mortgage payment Insurance on home Property taxes (if not included in mortgage) (if not included in mortgage) New amount $ $ $___________________ Are you a boarder? (A boarder pays a reasonable rate for lodging and at least two meals per day) Yes NO CHANGES IN UTILITIES OR DEPENDENT CARE COSTS List Utility or Dependent Care New amount How often billed $ $ $ Change Report – Page 3 CHANGES IN MEDICAL EXPENSES FOR ELDERLY OR DISABLED HOUSEHOLD MEMBER List Name of Elderly or Disabled Household Member: ___________________________________ Type of Medical Expenses Amount How often are you billed? 1. ________________________________________________ 2. ________________________________________________ 3. ________________________________________________ 4. ________________________________________________ ACQUISITION/SOLD OR TRADE OF VEHICLES OR ASSETS Has any household member who has been disqualified for intentional program violation acquired, sold or trade a car/truck, boat, camper, motorcycle or other assets such as property or land? Vehicle Make Model Year Value from sale or trade: $_____________________ CHANGES IN RESOURCES (SAVINGS, CHECKING, CDS, ETC.) List resources of any household member who has been disqualified for intentional program violation Type of resources:__________________________ Value of resources:__________________________ SINGLE WINNINGS OF $4,250 OR GREATER FROM LOTTERY OR GAMBLING Name of household member: ___________________________________________________________________ Gross amount of winnings before deductions: ______________________________________________________ Date of winnings:______________________________________________________________________________ Use this section for additional space, if needed, to report other changes household decides to report : Do you expect the changes you have reported on this form to remain the same for the next 30 days? Yes No If you answered no, please explain: IF YOUR BENEFITS CHANGE We will use your information reported on this form to determine if your household’s benefits will change. Before we change your benefits amount, we will send you a notice explaining what will happen. If you do not agree with our decision, you can request a fair hearing, and request that your benefits remain unchanged pending the hearing. However, should the hearing officer rule against the household, the household will have to repay any benefits receive that it was not entitled to. Change Report – Page 4 PENALTY WARNING IF ANY INFORMATION GIVEN BY YOU IS FOUND TO BE INCORRECT, THE SNAP HOUSEHOLD MAY BE DENIED SNAP BENEFITS. IF YOU, AN ADULT HOUSEHOLD MEMBER, OR THE HOUSEHOLD’S AUTHORIZE REPRESENTATIVE GIVE US FALSE INFORMATION ON PURPOSE, LEGAL ACTION MAY BE TAKEN AGAINST YOU OR YOUR HOUSEHOLD. YOU OR ANY ADULT MEMBER OF YOUR HOUSEHOLD MAY ALSO HAVE TO PAY BACK THE AMOUNT OF BENEFITS THAT THE HOUSEHOLD SHOULD NOT HAVE RECEIVED. IF YOUR HOUSEHOLD GET SNAP YOU MUST FOLLOW THE RULES LISTED BELOW. ANY ADULT HOUSEHOLD MEMBER FOUND GUILTY BY A COURT OR AN ADMINISTRATIVE DISQUALIFICATION HEARING OF BREAKING ANY OF THE FOLLOWING RULES OR WHO SIGNS A VOLUNTARY DISQUALIFICATION CONSENT AGREEMENT OR WAIVER OF AN ADMINISTRATION DISQUALIFICATION HEARING WILL BE BARRED FROM GETTING SNAP BENEFITS FOR: ONE YEAR FOR THE FIRST VIOLATION, TWO YEARS FOR THE SECOND VIOLATION, AND PERMANENTLY FOR THE THIRD VIOLATION. • DO NOT give false or incomplete information or hide information to get or continue to get SNAP. • DO NOT use SNAP benefits to buy ineligible items, such as alcohol drinks, and tobacco. • DO NOT use someone else’s SNAP EBT Card for your household. • DO NOT use your SNAP EBT card to purchase food on credit. • DO NOT attempt to buy or sell your SNAP benefits. I understand the penalty for hiding or giving false information, I also understand the household will owe the value of any extra SNAP received because I did not report the mandatory changes required to report . I agree to prove any changes reported , if asked . . My answers on this form are correct and complete to the best of my knowledge. Print Name:____________________________________ Signature:_____________________________ Date:___________________ Identify your relationship to household: ( ) Household Head ( ) Household Member ( ) Household’s Authorized Representative _______________________________________________________________________________________________________ In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508- 0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 Fax: (833) 256-1665 or (202) 690-7442; or email: Program.Intake@usda.gov ____________________________________________________________________________ For office use only: Worker’s Name______________________ Signature:____________________ Date:______________________________