Fillable Change Report Form Use this form to report

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Change Report Form Use this form to report

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GEN 55 (06-3621) rev 03/21 1 of 2
Change Report Form
Use this form to report changes in your household or family. The Division of Public Assistance needs to know
about these changes so we can determine your continued eligibility for assistance and benefit amount.
Changes must be reported within 10 days of when you know of the change (5 days when a child leaves the
home if you get Temporary Assistance). Attach proof of the change if you have it.
If your household only receives Supplemental Nutrition Assistance Program (SNAP) benefits, you only
need to report when your household’s total gross income goes over the income limit for your household
size, if someone in your household has lottery or gambling winnings of $3,500 or more in a single game,
and if a household member’s work hours fall below 20 hours per week if they are subject to the
ABAWD time limit.
Name Social Security # or Case Number
Primary Phone #
Which type of Public Assistance benefits does your household receive?
Please check.
Alaska Temporary Assistance SNAP Adult Public Assistance
Medicaid Senior Benefits CAMA
Change in employment
Whose employment changed?
Date of the change Job ended Job Started Job is Full-Time
Job is Part-Time
Employer’s name
Employer’s phone number
Hours per week Rate of pay $ per hour OR $
per month
How often paid? (weekly, bi-weekly, twice a month, monthly)
If this is a new job, when is the first check expected?
Do you expect this change in employment to last for the next couple of months? YES NO
Change in unearned income more than $50 a month (Child support, unemployment, social security, worker’s
compensation, veterans’ benefits, etc.)
Who receives it? Amount $
When is it received? What is the source of this income?
Someone moved in or out of the household
Who moved? Moved in or moved out? IN OUT When?
Relationship to you
Does this person buy and prepare food with you? YES
NO
Do you want this person included in your benefits? YES NO If yes, provide the following information:
Social Security #
US Citizen? YES NO Legal immigrant? YES
NO
Change in Pregnancy Status:
Who is pregnant? What is the expected delivery date?
How many babies expected this pregnancy?
GEN 55 (06-3621) rev 03/21 2 of 2
Moved or got a new mailing address
New home address
New mailing address
Date of move What are your new housing costs?
What utilities are you responsible for paying?
Someone got a vehicle (cars, trucks, boats, motorcycles, RVs, ATVs, snowmobiles, etc.)
Who? When?
Make Model Year
Value $ Amount owed $
How will this vehicle be used?
Did this replace a vehicle? YES
NO If yes, explain:
Household now has a combined total of $2,000 or more in cash and money in bank accounts
Explain:
Change in legal obligation to pay child support
Who in your household pays child support? Amount per month $
Change in medical coverage (only for Medicaid recipients)
Name(s)
Did coverage start or stop? START STOP Effective date of change
Insurance company name and address
Other Changes – Please explain
Please Sign Below
Under penalty of perjury, I certify that the information contained on this form is true and correct to the best of my
knowledge. I understand that proof of the changes I reported may be required.
Signature of person completing form Date
Once completed, this Chan
ge Report Form and related proof should be submitted to any Division of Public Assistance office
in person, by mail, by fax, or by email.
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Change Report Form Use this form to report

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Completed 3 April 2022

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