Information Verification

Change in Household Circumstances Form

Report any changes that could affect your SNAP, Child Care, TANF, Long Term Care, or Medical benefits. This helps make sure you get the right benefits. Report changes like: income, bank accounts or property, people moving in or out, your address, housing or utility costs, or your child care provider.

Case Validate
Contact Info
Changes to Report
Information Verification
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Summary

Validate Case Number

AFS Case Number

Please enter a case number that needs to be reported. Find your case number on the front of your EBT card (letter + 6 numbers) or on any notice from OKDHS.

SSN

Please enter a SSN to match the case number.

Date of Birth

Please enter a date of birth to match the case number.

Change in Household Circumstances Form

Contact Information

Case First Name

Case Last Name

Case Number

SSN

Date of Birth

Phone Number

Address

City

State

ZIP Code

Is your Street or Finding Address the same as your Mailing Address?

Yes

Is this a new address?

Yes

Please select the change type(s) to report:

Change in Expenses

Change in Household Members

Change in Income

Change in Child Care Provider

Change in Contact Information

Other Changes

Change in Household Circumstances Form

Person Completing Application

Please check below to indicate who is completing this Change in Household Circumstances form. If you are a contact person, authorized representative, have power of attorney for this person or household then check the ‘Authorized Representative’ checkbox and complete the following information. If you are an OKDHS employee acting as a proxy only to submit the change form, then check the ‘OKDHS Employee’ checkbox. If you are with a partner agency acting as a proxy only to submit the change form, then check the ‘Proxy Agent’ checkbox and complete the following information.

Self

Authorized Representative

OKDHS Employee

Proxy Agent

Change Reporting Requirements

Supplemental Nutrition Assistance Program (SNAP)

When you are approved for SNAP for less than 12 months, you must report the following changes within 10 calendar days of the change occurring. Report changes in:
• sources of income your household receives;
• earned or unearned income of $125 per month or more;
• household composition, such as when someone moves into or out of your home;
• your residence and any change in shelter costs because of the move;
• the amount of child support you pay to someone who does not live with you;
• the hours an able-bodied adult without dependents (ABAWD) works or participates in a work program when the hours drop below 20 hours per week averaged monthly; and
• resources when the household is first certified after a substantial lottery or gambling winning.

When you are approved for SNAP for 12 or 24 months, you must report when:
• your household income exceeds the income standard shows on Appendix C-3. Table I;
• a household member wins lottery or gambling winnings equal to or greater than $4,250; and
• the work or participation hours of an able-bodied adult without children drops below 20 hours per week averaged monthly.

You have 10 calendar days from the first payment that increased your income to report your household now receives too much income. You must report the work or participation hour change by the 10th of the month that follows this change.

Child Care Subsidy

Between renewal periods for Child Care Subsidy, you are only required to report within 10-calendar days of the change occurring when your household's gross income exceeds the federal exit income threshold for your household size, per OKDHS Appendix C-4, Child Care Eligibility/Copayment Chart.

Temporary Assistance to Needy Families (TANF), State Supplemental Payment (SSP), and SoonerCare

You are required to report the following changes within 10-calendar days of the date the change occurred.
• Sources and amounts of earned and unearned income,
• household composition;
• your residence; and
• resources or assets, such as bank accounts, vehicles, and property.

Voter Registration Information

If you want help filling out a voter registration application form, call (405) 522-5050 for assistance.

Non-Discrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Programs that receive federal financial assistance from the U.S. Department of Health and Human Services (HHS), such as Temporary Assistance for Needy Families (TANF), and programs HHS directly operates are also prohibited from discrimination under federal civil rights laws and HHS regulations.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language) should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

CIVIL RIGHTS COMPLAINTS INVOLVING USDA PROGRAMS
USDA provides federal financial assistance for many food security and hunger reduction programs such as the Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR), and others. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) (found online at: How to File a Complaint, and at any USDA office) or write a letter addressed to the USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by:
1. mail: Food and Nutrition Service, USDA
1320 Braddock Place, Room 334, Alexandria, VA 22314; or
2. fax: (833) 256-1665 or (202) 690-7442; or
3. phone: (833) 620-1071; or
4. email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov.

For any other information dealing with SNAP issues, persons should either contact the USDA SNAP hotline number at (800) 221-5689, which is also in Spanish, or call the state information/hotline numbers (click the link for a listing of hotline numbers by state); found online at: SNAP hotline.

CIVIL RIGHTS COMPLAINTS INVOLVING HHS PROGRAMS
HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head Start, LIHEAP, and others. If you believe that you have been discriminated against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual orientation, and gender identity), or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance, you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone else.

To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance through HHS, complete the form online through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or email: OCRmail@hhs.gov. For faster processing, we encourage you to use the OCR online portal to file complaints rather than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at OCRMail@hhs.gov or call OCR toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for filing a complaint.

This institution is an equal opportunity provider.

Electronic Signature and Release of Information

My signature authorizes the release of any necessary information, documents, or forms to OKDHS from persons, businesses, schools, banking institutions, data brokers, public or private organizations, Oklahoma state agencies, including personal and/or business income tax returns from the Oklahoma Tax Commission, or federal agencies to determine my eligibility for assistance.

My answers on this form are true, correct, and complete to the best of my knowledge. I understand there are specific penalties for fraudulent activities, such as hiding information, making false statements, or misusing benefits.

For SNAP, more penalties will result for more serious offenses, such as trafficking of SNAP benefits. For most situations, the penalties are loss of or reduction of benefits for:
• one year for the first offense,
• two years for the second offense, and
• permanently for the third offense.

I have agreed to submit this Change in Household Circumstances Form by electronic means. I understand that failure to sign this form and return required proof could result in the reported changes not being processed. I also have the option to contact my worker to complete this change form.

I accept the above statement

Attachment
Upload Document I don't have any documents to upload This is what you are submitting to DHS. You may upload up to 10 documents as long as they do not exceed 5 MB each. Select a Document Type to begin. Document Type Select Type of DocumentBirth CertificateChild Support Payment VerificationCollateral StatementCourt Orders/DocumentsDeath VerificationDeclaration of CitizenshipDependent Care VerificationEmployment VerificationHousehold CompositionIdentification DocumentIncarceration VerificationIncome VerificationMarriage LicenseOKDHSLIVE!/OKB UnassignedProof of CSS PaymentsShelter/Housing VerificationSocial Security CardSocial Security VerificationUtility Verification Sub Document Type Select Sub Type of Document Document Description Drag files here you wish to upload, or browse for them by clicking or pressing enter . Maximum of 10 files allowed.* Max Size: 5 MB Allowed Types: DOC, DOCX, JPG, PDF, TIFF, XLS, XLSX, PNG, GIF, TXT, RTF

Attachment

Upload Document

I don't have any documents to upload

This is what you are submitting to DHS. You may upload up to 10 documents as long as they do not exceed 5 MB each. Select a Document Type to begin.

Document Type

Select Type of Document

Birth Certificate

Child Support Payment Verification

Collateral Statement

Court Orders/Documents

Death Verification

Declaration of Citizenship

Dependent Care Verification

Employment Verification

Household Composition

Identification Document

Incarceration Verification

Income Verification

Marriage License

OKDHSLIVE!/OKB Unassigned

Proof of CSS Payments

Shelter/Housing Verification

Social Security Card

Social Security Verification

Utility Verification

Sub Document Type

Select Sub Type of Document

Document Description

Drag files here you wish to upload, or browse for them by clicking or pressing enter *.
Maximum of 10 files allowed.

Max Size: 5 MB
Allowed Types: DOC, DOCX, JPG, PDF, TIFF, XLS, XLSX, PNG, GIF, TXT, RTF