Monthly Change Report

All one-parent, two-parent and child-only benefit groups must complete and submit a Monthly Change Report (MCR) each month. Your monthly assistance payment will not be processed until you submit a completed Monthly Change Report, with all required verification documents attached, and your continued eligibility is determined. To prevent any delay, please answer all questions, attach required verification documents, sign and date the form and return this form by the fifth (5th) day of each month.

Adults included in a benefit group must submit a Work Participation Timesheet form, worksite timecard/timesheet, or other verification by the close of business on the fifth (5th) day of the month. If the fifth (5th) day of the month falls on a weekend, holiday, or authorized office closure day, timesheets/timecards must be received by the next business day.

In order to submit these documents online, you must have an email address.

If you do not have an email address, you can print a PDF version of the MCR form and submit it in person or by mail. Click here for the PDF version.

Office/Site(Required)

Name(Required)

First Last

Hidden

Date and Time Stamp

Call Back Phone(Required)

Email(Required)

CIF Number

Did your contact phone number change in the last 30 days?(Required)

If Yes, complete below.

Yes

New Contact Phone

Hidden

End of New Phone Information

Did your contact email address change in the last 30 days?(Required)

If Yes, complete below.

Yes

New Email

Hidden

End of New Email Information

Did your physical address change in the last 30 days?(Required)

If Yes, complete below.

Yes

Hidden

New Physical Information

New Physical Address

Street Address Address Line 2 City State Zip Code

Date Moved

Hidden

End of New Physical Information

Did your mailing address change in the last 30 days?(Required)

If Yes, complete below.

Yes

New Mailing Address

Street Address Address Line 2 City State ZIP Code

Hidden

End of New Mailing Information

Were you or any member in your household self-employed in the last 30 days?(Required)

If Yes, complete the Self-Employment Worksheet and attach at the end of the form.

Yes

Self Employment Worksheet may be required. You must complete an Self Employment Worksheet, if self-employed, and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

Hidden

End of Self-Employment

Were you or any member in your household employed part-time or full-time, other than self-employment, in the last 30 days?(Required)

If Yes, complete below and attach pay stubs or other proof of earnings.

Yes

Hidden

Income 1

Who received Income?

First Last

Total Monthly Amount Before All Deductions

Business Name

Business Phone Number

Do you have an additional income to report?

Yes

Hidden

Income 2

Who received Income?

First Last

Total Amount Before All Deductions

Business Name

Business Phone Number

Do you have an additional income to report?

Yes

Hidden

Income 3

Who received Income?

First Last

Total Monthly Amount Before All Deductions

Business Name

Business Phone Number

Do you have an additional income to report?

Yes

Hidden

Income 4

Who received Income?

First Last

Total Monthly Amount Before All Deductions

Business Name

Business Phone Number

Hidden

End of Earned Income Information

Did you or any member in your household receive unearned income or benefits from any other source in the last 30 days?(Required)

If Yes, complete below and provide proof. Examples: Per Capita, Child Support, Alimony support, interest or dividends; gambling/lottery winnings; insurance/legal settlements; Social Security, Supplemental Security Income (SSI), Unemployment, Worker’s Compensation, Royalty, Disability payments, Retirement benefits.

Yes

Hidden

Unearned Income or Benefits Information

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Would you like to add additional unearned income or benefits?

Yes

Hidden

Unearned 2

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Would you like to add additional unearned income or benefits?

Yes

Hidden

Unearned 3

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Would you like to add additional unearned income or benefits?

Yes

Hidden

Unearned 4

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Would you like to add additional unearned income or benefits?

Yes

Hidden

Unearned 5

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Would you like to add additional unearned income or benefits?

Yes

Hidden

Unearned 6

Who received Income?

First Last

Source of Income

Net Amount

Date Received

Other Source of Income

Hidden

End of Unearned Income or Benefits Information

Did a household member receive any State/Tribal public assistance in the last 30 days?(Required)

Examples: Food stamps, LIHEAP, Housing, Medicaid/Medical Assistance, General Assistance, Subsidized Child Care, etc.

Yes

Hidden

Assistance Information

Who received Assistance?

First Last

Type of Assistance

Amount

Date Received

Other Source of Assistance

Would you like to add additional assistance?

Yes

Hidden

Assistance 2

Who received Assistance?

First Last

Type of Assistance

Amount

Date Received

Other Source of Assistance

Would you like to add additional assistance?

Yes

Hidden

Assistance 3

Who received Assistance?

First Last

Type of Assistance

Amount

Date Received

Other Source of Assistance

Would you like to add additional assistance?

Yes

Hidden

Assistance 4

Who received Assistance?

First Last

Type of Assistance

Amount

Date Received

Other Source of Assistance

Hidden

End of Assistance Information

Did anyone move into or out of your home in the last 30 days?(Required)

Yes

Hidden

Household Information

Name of Person

First Last

Relation to Head of Household

Moved Status

Date Moved In/Out

Name of Person

First Last

Relation to Head of Household

Moved Status

Date Moved In/Out

Name of Person

First Last

Relation to Head of Household

Moved Status

Date Moved In/Out

Name of Person

First Last

Relation to Head of Household

Moved Status

Date Moved In/Out

Name of Person

First Last

Relation to Head of Household

Moved Status

Date Moved In/Out

Hidden

End of Household Information

Does any Household member have a checking or savings account?(Required)

If Yes, complete below and provide current bank statement.

Yes

Hidden

Account Information

Account Owner (First & Last Name)

Type of Account (Checking or Savings)

Value of Account

Hidden

End of Account Information

Please provide the following information for all school age children:

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 2

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 3

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 4

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 5

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 6

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 7

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 8

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 9

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Would you like to add additional school aged children?

Yes

Hidden

Child 10

Child Name

First Last

School Name

School Status

Attending

Withdrawn

Dropped Out

Expelled

Type of Instruction

Date Last Attended

Hidden

End of School Age Children

Upload Supporting Documents

Don’t forget to attach the Self-Employment Worksheet.

Drop files here or

Max. file size: 40 MB, Max. files: 20.

By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.