Report Change of Information Form:
Submitted By:
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==Please select==
Resident
HACF Staff
Power-of-Attorney
*IMPORTANT! - All Change of Information reporting must be completed using this online form!
Head of Household Name:
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Email:
*
Contact Phone Number:
*
DETAILS of CHANGE:
Effective Date of Change:
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First and Last Name:
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Type of Change:
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==Please select==
Employment
Social Security
TANF
Unemployment
Self-Employed
Child Support
Other - Explain Below
Status of Change:
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==Please select==
Started
Stopped
Changed
Increase
Decrease
Name of Employer:
*
Description of Change:
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Do you have any documents to upload along with this submission? If yes, click "Choose File" below::
Are you currently enrolled in the FSS Program?:
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Yes
No
Have you received TANF or been Employed in the prior 12 months?:
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Yes
No
Which site do you live at?:
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==Please select==
Westview
Gilmore
Willow
Douglas Village
Brewster
Hosmer
Parkside
Lincoln Village
CONFIRMATION:
IMPORTANT! Please read:
Under the penalty of perjury, I hereby certify that the declarations I have made in this document are true and complete. I understand and acknowledge that any knowing or willful misrepresentation of the declarations (including submission of falsified supporting documentation to support my declarations) contained in this document may result in civil liability and/or criminal penalties, included but not limited to fine or imprisonment, or both under the provisions of Title 18 of the United States Code (USC), Section 1001. A person convicted of violation 18 USC 1001, shall be fined not more than $10,000, or imprisoned not more than 8 years, or both.
I agree to terms & conditions.:
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I agree to terms & conditions.
Verify by entering the last four of your social security number of Head of Household:
*