
2
3. Has anyone started a job since last reported? No Yes
If yes, enter name______________________________________ and complete the following:
Name of Employer_________________________________Phone Number_________________
Hours Worked Per Week_________________Hourly Rate or Salary_______________________
Day of Week Paid______________ How Often Paid_________Date of First Pay_____________
If anyone has started a job, please provide the most recent 30 days of paystubs.
4. Has anyone stopped a job since last reported? No Yes
If yes, explain:_________________________________________________________________
5. For all persons in your home that are getting other income (child support, Social Security, SSI,
VA, Unemployment Benefits, etc.), has that income changed by more than $50? No Yes
If yes, explain:_________________________________________________________________
6. Has the amount of cash on hand, stocks, bonds or money in a bank account or savings institution
reached or gone over $2,250? No Yes
If yes, explain: _________________________________________________________________
7. Have you moved? No Yes
If yes, answer the following questions:
a. Your new address:___________________________________________________________
b. Date moved:________________________________________________________________
c. Landlord name, address and phone______________________________________________
__________________________________________________________________________
d. Rent/mortgage amount:_______________________________________________________
e. Property taxes not included in mortgage (if applicable)_______________________________
f. Homeowners insurance not included in mortgage (if applicable)________________________
g. Do you pay for heating or cooling at your new address? No Yes
8. For all persons in your home that have a legal obligation to pay child support, have there been
any changes in the legal obligation to pay child support (court ordered amount increased or
decreased)? No Yes
If yes, explain:_________________________________________________________________
_____________________________________________________________________________
If yes, please provide proof of the change in your legal obligation to pay child support.
9. List any other information you would like DCF to know:_________________________________
_____________________________________________________________________________
_____________________________________________________________________________
10. Signature and Date:
I UNDERSTAND THE QUESTIONS ON THIS FORM, AND I CERTIFY, UNDER PENALTY OF
PERJURY, THAT THE INFORMATION GIVEN BY ME ON THIS FORM IS CORRECT AND
COMPLETE TO THE BEST OF MY KNOWLEDGE. I also understand that any changes reported
on this form may result in a reduction or termination of benefits. I also understand that if I am
found guilty of fraud I may not get food assistance for one year for the first offense, two years for
the second offense and permanently for the third offense.
SIGNATURE___________________________________DATE___________________________
TELEPHONE NUMBER WHERE YOU CAN BE REACHED______________________________