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2. Client Information
4. Please fill out all these fields, then scroll down to fill out the sections that apply to you.
6. Client Name*
8. Phone number*
10. Email Address
12. Date of birth
14. If you are NOT registered to vote where you live, would you like to receive a form to register to vote? *

    1. Yes

    1. No
16. Household Information
18. Street Address (house number, street name, apartment number if there is one)*
20. City*
22. State*
23. Zip Code*
24. Is this a new address?*

    1. Yes
    2. No
26. Who lives in the home?*
28. Tell us about your change*
30. Which program/s are you receiving?

    1. Food & Nutrition Services
    2. Family & Children Medicaid
    3. Adult Medicaid
    4. Energy Programs (CIP/LIEAP)
    5. Non-Emergency Medical Transportation
    6. Work First Family Assistance
    7. Child Care Subsidy
32. Supporting Documents
    Please upload any documents to help us verify your changes.
34. Supporting Document
35. Supporting Document
36. Supporting Document
40. Changes in Expenses
42. Rent/Mortgage Amount $:
43. Homeowners Insurance $:
44. Do you pay for heating/cooling?

    1. Yes
    2. No
46. Do you pay for any of the following?
48. Daycare

    1. Yes
    2. No
49. How much for daycare?
50. How often do you pay for daycare (weekly, monthly, etc)
52. Child Support

    1. Yes
    2. No
53. How much child support?
54. How often do you pay child support? (weekly, monthly, etc)
56. Medical

    1. Yes
    2. No
57. How much medical cost?
58. How often do you pay? (weekly, monthly, etc)
60. Health Insurance

    1. Yes
    2. No
61. How much for Health Insurance?
62. How often do you pay for health insurance? (weekly, monthly, etc)
66. Changes in Employment-Person 1
68. How has your employment changed?

    1. New
    2. Terminated
    3. Reduction in hours
69. For which member of your household?
70. Employer
72. Start Date
73. Rate of Pay
74. Hours worked per week
76. How often are you paid?

    1. Weekly
    2. Bi-weekly

    1. Semi-monthly
    2. Monthly
77. Are your reduced hours permanent?

    1. Yes
    2. No
79. Date you stopped working
80. Date of final pay
81. Amount of final pay
85. Changes in Employment-Person 2
87. How has your employment changed?

    1. New
    2. Terminated
    3. Reduction in hours
88. For which member of your household?
89. Employer
91. Start Date
92. Rate of Pay
93. Hours worked per week
95. How often are you paid?

    1. Weekly
    2. Bi-weekly

    1. Semi-monthly
    2. Monthly
96. Are your reduced hours permanent?

    1. Yes
    2. No
98. Date you stopped working
99. Date of final pay
100. Amount of final pay
104. Changes in Income-Person 1
106. How has your income changed?

     1. New
     2. Terminated
     3. Reduction
107. For which member of your household?
108. How much has your income changed?
109. How often? (weekly, monthly, etc)
111. Income Type

     1. Social Security
     2. Child Support

     1. VA
     2. Other
112. If Other, please explain
116. Changes in Income-Person 2
118. How has your income changed?

     1. New
     2. Terminated
     3. Reduction
119. For which member of your household?
120. How much has your income changed?
121. How often? (weekly, monthly, etc)
123. Income Type

     1. Social Security
     2. Child Support

     1. VA
     2. Other
124. If Other, please explain
128. Tax Filing Status
130. Will anyone in the household file a federal tax return next year?

     1. Yes

     1. No
131. If yes, who?
133. Will you file jointly with a spouse?

     1. Yes

     1. No
134. If yes, who?
136. Will you claim any dependents on your tax return?

     1. Yes

     1. No
137. If yes, who?
139. Will someone in the household be claimed by someone who does not live in the home?

     1. Yes
     2. No
140. If yes, who?
141. Claimed by
142. Relationship
146. Number of students 16 or older in the home
147. Which school/s?
149. Is anyone in the household pregnant?

     1. Yes

     1. No
150. If yes, estimated due date
152. Does anyone in the household want to change their primary care provider?

     1. Yes

     1. No
153. If yes, who would you like to change to?
Leave This Blank:


155. 1. Receive an email copy of this form.
156. Email address

     This field is not part of the form submission.

157. Submit

* indicates a required field