Form DWS-ESD475 "Change Report Form" - Utah

What Is Form DWS-ESD475?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWS-ESD475 by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DWS-ESD475 "Change Report Form" - Utah

Download PDF

Fill PDF online

Rate (4.7 / 5) 15 votes
DWS-ESD 475
State of Utah
Rev. 04/2019
Department of Workforce Services
CHANGE REPORT FORM
Name:
SSN:
Case #:
D10819900440102
We no longer need the following types of assistance:
Financial
Medicaid
SNAP
Child Care
Signature:
Reason:
Complete and sign this form only if you have a change. You are required to report different things depending on what
kind of benefits you receive. If you have questions about how to fill out this form, call 1-866-435-7414. For Medical,
Child Care and Financial, you are required to report the changes listed below within 10 days. For SNAP, you are
th
required to report the changes below by the 10
day of the month following the change. Any false or unreported
information that is discovered may result in an overpayment and/or prosecution for fraud. Do not delay reporting
changes.
For SNAP and Financial, you must always report:
If your total household income (before anything is taken out) becomes more than: $________ per month
If you receive SNAP and you are able-bodied between the ages of 18-49 with no children living in your
household you must also report:
If your employment hours fall below 20 hours per week.
If you receive Financial Assistance you must also report:
If you move or change your address
If a parent, stepparent, or spouse moves into the home
A change in marital status
If a child moves in or moves out of the home
A child in the home is adopted
If a child in the home becomes eligible for foster care or subsidized adoption financial assistance
If there is a change in the student status of a child in the home
If a client receiving Transitional Cash Assistance (TCA) is no longer employed or is working less than an
average of 30 hours per week
If there is a change in disability status of a client receiving General Assistance
If a client receiving General Assistance becomes employed
If you receive Child Care Assistance you must report:
If you move or change your address.
A child receiving Child Care Assistance moves out of the home.
You no longer need Child Care Assistance or the child stops attending.
If you change your child care provider.
If your gross income exceeds 85% state median income for your household size.
If you receive Medical Assistance you must report:
Change in an income source (only required at review for UPP and Targeted Adult Medicaid).
Change of more than $25 in gross monthly income (only required at review for UPP, CHIP and
Targeted Adult Medicaid).
Receipt of a lump sum, such as SSA benefits, insurance payments, and accident, or injury awards
(only required at review for UPP, CHIP and Targeted Adult Medicaid).
A change in expenses paid, such as child care.
A change in assets, such as gaining or losing a vehicle, opening a bank account (not required for
Child or Family Medicaid, CHIP, UPP and Targeted Adult Medicaid).
Gain or loss of health insurance coverage or a change in the health insurance premium or plan.
Change in household size, address, living arrangement, marital, or pregnancy status.
Change in the type of residence, such as entering or leaving an institution.
DWS-ESD 475
State of Utah
Rev. 04/2019
Department of Workforce Services
CHANGE REPORT FORM
Name:
SSN:
Case #:
D10819900440102
We no longer need the following types of assistance:
Financial
Medicaid
SNAP
Child Care
Signature:
Reason:
Complete and sign this form only if you have a change. You are required to report different things depending on what
kind of benefits you receive. If you have questions about how to fill out this form, call 1-866-435-7414. For Medical,
Child Care and Financial, you are required to report the changes listed below within 10 days. For SNAP, you are
th
required to report the changes below by the 10
day of the month following the change. Any false or unreported
information that is discovered may result in an overpayment and/or prosecution for fraud. Do not delay reporting
changes.
For SNAP and Financial, you must always report:
If your total household income (before anything is taken out) becomes more than: $________ per month
If you receive SNAP and you are able-bodied between the ages of 18-49 with no children living in your
household you must also report:
If your employment hours fall below 20 hours per week.
If you receive Financial Assistance you must also report:
If you move or change your address
If a parent, stepparent, or spouse moves into the home
A change in marital status
If a child moves in or moves out of the home
A child in the home is adopted
If a child in the home becomes eligible for foster care or subsidized adoption financial assistance
If there is a change in the student status of a child in the home
If a client receiving Transitional Cash Assistance (TCA) is no longer employed or is working less than an
average of 30 hours per week
If there is a change in disability status of a client receiving General Assistance
If a client receiving General Assistance becomes employed
If you receive Child Care Assistance you must report:
If you move or change your address.
A child receiving Child Care Assistance moves out of the home.
You no longer need Child Care Assistance or the child stops attending.
If you change your child care provider.
If your gross income exceeds 85% state median income for your household size.
If you receive Medical Assistance you must report:
Change in an income source (only required at review for UPP and Targeted Adult Medicaid).
Change of more than $25 in gross monthly income (only required at review for UPP, CHIP and
Targeted Adult Medicaid).
Receipt of a lump sum, such as SSA benefits, insurance payments, and accident, or injury awards
(only required at review for UPP, CHIP and Targeted Adult Medicaid).
A change in expenses paid, such as child care.
A change in assets, such as gaining or losing a vehicle, opening a bank account (not required for
Child or Family Medicaid, CHIP, UPP and Targeted Adult Medicaid).
Gain or loss of health insurance coverage or a change in the health insurance premium or plan.
Change in household size, address, living arrangement, marital, or pregnancy status.
Change in the type of residence, such as entering or leaving an institution.
AND if you receive Child, Family or Targeted Adult Medicaid, CHIP, UPP and Adult
Expansion you must also report:
Change in tax filing status or the number of dependents claimed on your taxes (only
required at review for UPP, CHIP and Targeted Adult Medicaid).
Change in earnings of a child (only required at review for UPP or CHIP).
Change in student status of a child (only required at review for UPP or CHIP).
For CHIP, a recipient having access to coverage under a health insurance plan.
For CHIP, the changes you are required to only report at review are still reportable up
D10819900440202
until the month of the new certification period.
You can report your changes online at https://jobs.utah.gov/mycase, by phone, by mail, fax or in person at your local
DWS office.
Please explain your changes:
If you have moved:
What is your new address?
City:
State:
Zip Code:
How much do you pay for rent/mortgage?
$
per month
What utilities do you pay?
Heating
Cooling
Phone
Electric
Water/Sewer/Garbage
Is someone else helping you pay these expenses (family member, organization, state agency, etc.)?....
Yes
No
If yes, who?
Your portion: $
Their portion: $
Agreement to report:
I,
, read or had read to me the statements above. I understand those
statements. I understand I must report changes in my situation within 10 days of the day I learn of the change
to my local Department of Workforce Services or Bureau of Eligibility Services office. I understand I will then
have 10 days to provide verification of the reported change.
I understand that any false or unreported
information that is discovered may result in prosecution for fraud. I understand that I may request a fair hearing
if I disagree with any action made on, my case.
Customer Signature
Date
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
Page of 2