Fillable DHS-2240- Bridges, Change Report (Michigan)

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DHS-2240- Bridges, Change Report (Michigan)

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DHS-2240 (Rev. 9-11)
Web
Case Name:
Case Number:
Date:
CHANGE REPORT
Use this form to report changes about anyone in your home within 10 days of the time you learn of them (For earned income,
within 10 days of receiving of your first payment.) If you cannot mail this form, report the change by calling your DHS specialist.
1. PERSONS IN YOUR HOME
List anyone who: • Was Born--Enter newborn’s date of birth ______________________
• Died • Got Married or Divorced • Moved In or Out • Began or Ended a Pregnancy • Entered or Left a Nursing Home
• Is Temporarily Away From Your Home.
PERSON’S NAME RELATIONSHIP TO YOU DATE OF BIRTH
WHAT WAS THE CHANGE? DATE OF CHANGE
2. HOUSEHOLD INCOME
Did anyone: start working, have a change in rate of pay, change employers, have a change in the number of hours worked per week of
more than 5 hours since last report that will continue for more than one month, stop working? Did anyone: start or stop getting Social
Security, a pension, UCB, child support or other unearned income. Did the household’s gross unearned income go up or down by more
than $50 per month since your last reported change? If receiving Medicaid only (except for Healthy Kids), you must report a change in
gross monthly unearned income of more than $25.
ATTACH a written statement SIGNED BY EMPLOYER, listing your work schedule (days and times) if you use day care and your
work schedule has changed.
SEND PROOF OF INCOME: Include your name and case number on it so we may return it to you.
PERSON WITH
INCOME
CHANGE
TYPE OF
INCOME
DID INCOME
START, STOP
OR CHANGE?
IS THE
CHANGE
EXPECTED TO
CONTINUE?
(Yes/No)
NUMBER OF
EXPECTED
HOURS OF
WORK PER
WEEK
HAS WORK
SCHEDULE
CHANGED?
AMOUNT
RECEIVED?
HOW OFTEN IS INCOME
RECEIVED?
(Weekly, Bi-Weekly, Monthly,
etc.)
3. EDUCATION OR WORK-RELATED ACTIVITIES
Did anyone participate in an approved employment-related activity, such as: a work participation program, high school completion, GED or
college, etc. ATTACH NEW CLASS SCHEDULE TO THIS FORM IF CHANGED.
LIST PERSON IN ACTIVITY TYPE OF ACTIVITY
HAS CLASS SCHEDULE
CHANGED? (Yes/No)
DID ACTIVITY START,
STOP, OR CHANGE?
NUMBER OF HOURS OF
EXPECTED
PARTICIPATION PER WEEK
over
Enter DHS Office
Enter DHS Office Address 1
Enter DHS Office PO Box or Street
Enter DHS Office City/State/Zip
Enter Addressee Name
Enter Addressee Care Of
Enter Addressee PO Box or Street
Enter Addressee City/State/Zip
DHS-2240 (Rev. 9-11) Web
4. CHILD DAY CARE OR DISABLED ADULT CARE
Report any need for or change in child or disabled adult care such as changes in: need, days and times care is provided, provider changes,
where care is provided, provider charges, etc. Do you receive help to pay for this care? ____ Yes ____ No
PERSON RECEIVING
CARE
AGE
REASON FOR CARE(Work,
School, Training,
Medical/Social)
DATE OF CHANGE? NAME OF THE PROVIDER
PROVIDER ID
NUMBER
a.
b.
c.
d.
PERSON RECEIVING
CARE (List the same
person as above)
DAYS AND TIMES CARE IS
PROVIDED
IS CARE PROVIDED IN CHILD’S
HOME?
IS PROVIDER RELATED TO
THE CHILD
RATE CHARGED AND
HOW OFTEN (Hourly,
Daily, Weekly, etc.)
a.
$ per
b. $ per
c. $ per
d. $ per
5. ASSETS
Report if anyone has opened or closed any accounts such as: bank, retirement or CD, or bought, sold, transferred, given away, or received
any other asset such as: land, cars, and other vehicles, boats, life insurance, investments, lawsuit settlements or any other property.
WHAT CHANGED?
PLEASE EXPLAIN THE CHANGE
6. OTHER CHANGES
Report if anyone has a change such as: address, rent, mortgage, taxes, insurance (home or health), utility costs, child support paid,
medical expenses, school attendance.
PERSON WITH CHANGE DATE OF CHANGE PLEASE EXPLAIN THE CHANGE
7. Do you expect the changes you reported to continue next month?
If no, please explain below.
Yes
No
I understand that the information I provide on this report form may result in changes in my assistance, including reducing the amount of my checks (Cash
Assistance, employment-related services and/or Child Development and Care), Food Assistance benefits and medical assistance, or closing my case. I
understand that such changes may be made without advance notice. I am aware that, if I give false information which causes me to receive assistance
I am not entitled to, or more assistance than I am entitled to, I can be prosecuted for fraud. I must report all changes in my situation within 10 days of
learning of the change, or for earned income, within 10 days of the start date of employment.
I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Client’s Signature or Mark
Date
Client’s Telephone Number
Signature of Other Person Completing Form or Witness Date
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height,
weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing,
etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
“In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex, age, religion, political beliefs, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call
toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at
(800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”
AUTHORITY: Act 280 of 1939, Food Stamp Act of 1977 COMPLETION: Voluntary PENALTY: Loss of eligibility for assistance benefits
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DHS-2240- Bridges, Change Report (Michigan)

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Completed 2 March 2022

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