Change Report Form

STATE OF NEVADADEPARTMENT OF HEALTH AND HUMAN SERVICESRICHARD WHITLEY, MSDIVISION OF WELFARE AND SUPPORTIVE SERVICESD irectorROBERT THOMPSONA dministratorSTEVE SISOLAKG overnor2584 - EG ( )Page 1 of 2 Change Report FORMTHE LAW SAYS YOU MUST Report CHANGES TO US WITHIN 10 DAYS AFTER THE Change HAPPENS IF YOU ARERECEIVING SNAP BENEFITS AND BY THE 5TH OF THE FOLLOWING MONTH FOR TANF AND/OR MEDICAL in the spaces below. (You can write an explanation on a separate sheet of paper.) You can mail or bring this Report into the PROVIDE PROOF OF THE SECURITY #CITY/ZIP CODEHOME PHONECELL PHONEE-MAILIs this a new address?YESNOMAILING ADDRESS (If different)PEOPLE CHANGES:Did someonemove in move outor have a baby? Please provide details MOVEDIN OR OUTDATE OFBIRTHSOCIALSECURITY the member moving in a tax filer? YESNOIs the member moving in a tax dependent? YES NOIf yes, who claims this member as a tax dependent?INCOME AND JOB CHANGES Did someone get a new job?

HOME PHONE. CELL PHONE. E-MAIL. Is this a new address? YES. NO. MAILING ADDRESS (If different) PEOPLE CHANGES: Did someone move in. move out. or have a baby? Please provide details below. NAME. DATE MOVED IN OR OUT. DATE OF BIRTH. SOCIAL SECURITY NO. RELATIONSHIP. Is the member moving in a tax filer? YES. NO. Is the member moving in a tax ...

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