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I. Purpose
The purpose of this release is to introduce the revised (1/03) LDSS-3151: "Food Stamp Change Report Form". This mandated form is used by local districts to solicit information from Food Stamp benefits recipients on changes in household circumstances.
The primary reasons for this revision are:
* To clarify when and what changes recipients must report in accordance with the expanded six-month reporting rules.
* To inform recipients of their obligation to report changes at designated six-month checkpoints.
* To reinforce with recipients their monthly obligation to report total gross monthly income in excess of the 130% federal gross poverty level.
The following are the changes to the 5/02 "Food Stamp Change Report Form" which are incorporated into the 1/03 version:
A. Page 1
1. The revision date was changed from 5/02 to 1/03.
2. The section title under the Address box , "Food Stamp Reporting Rules for households with earned income (six-month reporters):" was changed to "Food Stamp Reporting Rules for households with income (six-month reporters):".
3. The wording for the revised "Food Stamp Reporting Rules for households with income (six-month reporters):" section was changed to read:
Food Stamp Reporting Rules for households with income (six-month reporters):
As a household with income, you are now only required to report changes about your Food Stamp household at the time of your next recertification, except for the following situations:
1. If your household's gross monthly income exceeds 130% of the poverty level, you must report this monthly amount to your social services district by telephone, in writing, or in person within 10 days after the end of the calendar month. Gross income is the amount of income before taxes and other deductions are taken out, not the amount you receive when you cash your check. We must use the gross income in figuring your eligibility for Food Stamp benefits. Your worker will explain what 130% of the poverty level means for a family of your size. Any other kind of income that you receive besides earnings must be added to your gross earned income to know if you are over 130% of the poverty level. Examples of other sources of income that count include child support payments, Unemployment Insurance, Temporary Assistance (TA) payments, Worker's Compensation or disability payments such as Social Security, SSI or private disability payments.
If you fail to report that your gross income is above 130% of the poverty level in any calendar month, all benefits received after that month may be considered an overpayment. This is true even if your gross income falls below the 130% poverty level in a future month.
2. If your household's certification period is longer than 6 months, and no one in your household receives Temporary Assistance (TA): At a six-month checkpoint into your certification period, if your household has any of the changes listed below, you are required to report them on this change report form within ten days after you receive the form.
NOTE: At this six-month checkpoint you do not have to return this form unless your household has had any of the changes listed below.
List of Changes you must report at the six-month checkpoint:
· Changes in any source of income for anyone in your household.
· Changes in your total household earned income when it goes up or down
by more than $100 a month.
· Changes in your total household unearned income when it goes up or
down by more than $25 a month if received from a public source such as
Social Security Benefits or Unemployment Insurance Benefits (UIB), etc.
· Changes in your total household unearned income when it goes up or
down by more than $100 a month if received from a private source such as
Child Support Payments or Private Disability Insurance Payments, etc.
· Changes of $100 or more in court ordered child support paid to a child
outside of the Food Stamp Household.
· Changes in the number of people in your household.
· Your new address, if you move.
· Your new rent or mortgage costs, if you move.
· A new or different car, or other vehicle.
· Increases in your household's cash, stocks, bonds, money in the bank or
savings institution if the total cash and savings of all household members
now amounts to $2000 or more. ($3000 or more if one household member
is disabled or 60 years old or older).
· Any changes in your household that would result in a penalty as described
on page 5.
B. Page 2
1. The revision date was changed from 5/02 to 1/03.
2. A new section was added called "Exceptions To Six-Month Reporting Rules". The new section reads as follows:
Exceptions To Six-Month Reporting Rules - You must report all of the changes listed on Page 1 in item # 2 within ten days after the change occurs if your household:
· had no income, or
· gets SSI or SSA and lives in a certified congregate care group home, or
· includes a seasonal migrant farm-worker, or
· was certified for less than four months, or
· is homeless (undomiciled - without shelter), or
· includes an Able-Bodied Adult Without Dependents ("ABAWD"): you must tell us if your work hours go below 80 hours a month within 10 days after the end of the month.
3. The statement at the bottom of Page 2 was changed to read:
IF YOU WITHHOLD INFORMATION ABOUT CHANGES IN YOUR
HOUSEHOLD THAT YOU ARE REQUIRED TO REPORT, YOU WILL OWE US THE VALUE OF ANY EXTRA FOOD STAMP BENEFITS YOU RECEIVE AS A RESULT. IF YOU INTENTIONALLY WITHHOLD INFORMATION,YOU MAY ALSO BE DISQUALIFIED FROM THE FOOD STAMP PROGRAM AND COULD BE SUBJECT TO CRIMINAL PROSECUTION (SEE ATTACHED "FOOD STAMP PENALTY WARNING").
C. Page 3
1. The revision date was changed from 5/02 to 1/03.
2. The shaded gray area on Page 3 that discusses "Change in Income or source of
income" was revised and an additional section was added to discuss "Exception
Reporters". This area shoud now read:
CHANGE IN INCOME OR SOURCE OF INCOME - Six-Month Reporters - If you are subject to six-month reporting requirements you need to report, within 10 days of the end of the month, changes in your gross monthly income when it exceeds 130% of the poverty level. If your household is certified for more than seven months, has only unearned income and does not receive Cash Temporary Assistance, 6 months into your certification period you are required to report any changes in your household on this mail report form. If your household is certified for more than seven months and either has earned income or receives Cash Temporary Assistance, 6 months into your certification period you will be sent a different form which must be completed and returned (regardless of changes) to report your household circumstances. Otherwise, changes in your gross monthly income that do not exceed 130% of the poverty level must be reported at your next recertification.
Exception Reporters - If your household is in one of the situations described above under "Exceptions Reporting Rules": You must tell us if the total unearned income received by your household goes up or down by more than $25 a month if received from a public source such as Social Security Benefits or Unemployment Insurance Benefits (UIB), etc. You must also tell us if the total unearned income received by your household goes up or down by more than $100 a month if received from a private source such as Child Support Payments or Private Disability Insurance Payments, etc. Additionally, you must also tell us if the total earned income received by your household goes up or down by more than $100 a month. In figuring the change, use your household's total monthly income before deductions such as taxes, retirement or union dues, are taken out. You do not have to report changes in your temporary assistance. You must also tell us if there is a change in your source of income.
D. Page 4 - The revision date was changed from 5/02 to 1/03.
E. Page 5
1. The revision date was changed from 5/02 to 1/03.
2. The "FOOD STAMP PENALTY WARNING SECTION " was changed on Page 5 to mirror the "FOOD STAMP PENALTY WARNING SECTION" on Page 15 of the 5/02 version of the LDSS-2921: Statewide Application". The new language should read as follows:
FOOD STAMP BENEFITS (FS) PENALTY WARNING
Any information you provide in connection with your application for Food Stamp Benefits will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied FS. You may be subject to criminal prosecution for knowingly providing incorrect information.
You will never be able to get FS again if you are:
· Found guilty in a court of law of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor's prescription is required) in exchange for FS; or
· Found guilty in a court of law of selling or getting firearms, ammunition or explosives in exchange for FS; or
· Found guilty in a court of trafficking in FS worth $500 or more.
Trafficking includes the illegal use, transfer, acquisition, alteration or possession of FS, authorization cards or access devices; or
· Found guilty of committing a third Intentional Program Violation (IPV).
If you have committed your:
· First IPV, you will not be able to get FS for one year.
· Second IPV, you will not be able to get FS for two years.
A court could also bar you from receiving Food Stamp Benefits for an additional 18 months.
If you make a false statement about who you are or where you live in order to get multiple FS, you will not be able to get FS for ten years (or permanently if this is the third IPV).
You may be found guilty of an Intentional Program Violation if you:
· Make a false or misleading statement, or misrepresent, conceal or withhold facts; or
· Commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of coupons, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.
You could also be fined up to $250,000, sent to jail for up to 20 years, or both.
3. The following phrase was added to the end of the first sentence of the "CERTIFICATION" section. The revised sentence should now read:
I understand the penalty for hiding or giving false information. I also understand I
will owe the value of any extra Food Stamp benefits I receive because I don't fully report changes in my household that I am required to report.
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