Form FSP-922 Change Report Form for Food Stamp Non-simplified Reporting Cases - Burlington County, New Jersey

Form FSP-922 is a Burlington County Board of Social Services form also known as the "Change Report Form For Food Stamp Non-simplified Reporting Cases". The latest edition of the form was released in May 1, 2010 and is available for digital filing.

Download an up-to-date Form FSP-922 in PDF-format down below or look it up on the Burlington County Board of Social Services Forms website.

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FSP-922 (Rev. 5/10)
(Page 1)
CHANGE REPORT FORM FOR FOOD STAMP NON-SIMPLIFIED REPORTING CASES
This form is to be used to notify your food stamp office of any changes in your household's circumstances. You can also
call _______________________________________ to report changes.
YOU MUST REPORT THE FOLLOWING CHANGES WITHIN 10 DAYS OF FINDING OUT ABOUT THEM.
ALL CHANGES IN HOUSEHOLD COMPOSITION (SUCH AS SOMEONE ENTERING OR LEAVING YOUR
HOUSEHOLD).
CHANGES IN RESIDENCE AND ANY CHANGES IN SHELTER COSTS (SUCH AS RENT OR MORTGAGE
COSTS) WHICH RESULT FROM MOVING.
NEW EARNED INCOME AND/OR UNEARNED INCOME (SUCH AS, EMPLOYMENT, UIB, CHILD SUPPORT, SSI,
ETC).
INSTRUCTIONS: COMPLETE THE INFORMATION BELOW AND RETURN IT TO THE FOOD STAMP OFFICE.
NAME:
___________________________________DAYTIME PHONE# _____________________
ADDRESS: _____________________________________________CASE NO. ________________
THIS IS TO INFORM YOU THAT:
( )
1.
I (we) have moved to ___________________________________________________ on ________________
(give new address)
(date moved)
( )
2.
A new member has been added to our household.
Date Added:_______________ Name:________________________________________________
Relationship:________________
Date of Birth:___________ Social Security#:_________________
Source of income:______________________________________
( )
3.
A member has moved out of our household.
Name:____________________________________
Date moved:___________________________
Relationship:______________________________
Source of Income:_______________________
( )
4.
This change will happen this month only. ( )Yes ( ) NO, IT WILL CONTINUE.
( )
5
I (we) have new earned income ____________________
New unearned income ____________________
( )
6.
Other changes you might want to report but are not required to report: (such as changes in shelter costs
even if you have not moved, medical expenses, etc.)
________________________________________________________________________________________
________________________________________________________________________________________
REMEMBER: you are eligible for the standard utility allowance, you must utilize it. Households with elderly or disabled
members may qualify for the excess shelter deduction.
ANY MEMBER OF YOUR HOUSEHOLD WHO BREAKS ANY OF THE FOLLOWING RULES ON PURPOSE WILL NOT
BE ABLE TO GET FOOD STAMP BENEFITS FOR 12 MONTHS AFTER THE FIRST TIME, 24 MONTHS AFTER THE
SECOND TIME, AND PERMANENTLY AFTER THE THIRD TIME. A COURT CAN ALSO ORDER THE PERSON OFF
FOOD STAMP BENEFITS FOR AN ADDITIONAL 18 MONTHS.
THE PERSON CAN ALSO BE FINED UP TO
$250,000, SENT TO JAIL FOR UP TO 20 YEARS OR BOTH. UNDER OTHER FEDERAL LAWS, ADDITIONAL
CRIMINAL OR CIVIL ACTION MAY BE TAKEN AGAINST THE INDIVIDUAL.
FSP-922 (Rev. 5/10)
(Page 1)
CHANGE REPORT FORM FOR FOOD STAMP NON-SIMPLIFIED REPORTING CASES
This form is to be used to notify your food stamp office of any changes in your household's circumstances. You can also
call _______________________________________ to report changes.
YOU MUST REPORT THE FOLLOWING CHANGES WITHIN 10 DAYS OF FINDING OUT ABOUT THEM.
ALL CHANGES IN HOUSEHOLD COMPOSITION (SUCH AS SOMEONE ENTERING OR LEAVING YOUR
HOUSEHOLD).
CHANGES IN RESIDENCE AND ANY CHANGES IN SHELTER COSTS (SUCH AS RENT OR MORTGAGE
COSTS) WHICH RESULT FROM MOVING.
NEW EARNED INCOME AND/OR UNEARNED INCOME (SUCH AS, EMPLOYMENT, UIB, CHILD SUPPORT, SSI,
ETC).
INSTRUCTIONS: COMPLETE THE INFORMATION BELOW AND RETURN IT TO THE FOOD STAMP OFFICE.
NAME:
___________________________________DAYTIME PHONE# _____________________
ADDRESS: _____________________________________________CASE NO. ________________
THIS IS TO INFORM YOU THAT:
( )
1.
I (we) have moved to ___________________________________________________ on ________________
(give new address)
(date moved)
( )
2.
A new member has been added to our household.
Date Added:_______________ Name:________________________________________________
Relationship:________________
Date of Birth:___________ Social Security#:_________________
Source of income:______________________________________
( )
3.
A member has moved out of our household.
Name:____________________________________
Date moved:___________________________
Relationship:______________________________
Source of Income:_______________________
( )
4.
This change will happen this month only. ( )Yes ( ) NO, IT WILL CONTINUE.
( )
5
I (we) have new earned income ____________________
New unearned income ____________________
( )
6.
Other changes you might want to report but are not required to report: (such as changes in shelter costs
even if you have not moved, medical expenses, etc.)
________________________________________________________________________________________
________________________________________________________________________________________
REMEMBER: you are eligible for the standard utility allowance, you must utilize it. Households with elderly or disabled
members may qualify for the excess shelter deduction.
ANY MEMBER OF YOUR HOUSEHOLD WHO BREAKS ANY OF THE FOLLOWING RULES ON PURPOSE WILL NOT
BE ABLE TO GET FOOD STAMP BENEFITS FOR 12 MONTHS AFTER THE FIRST TIME, 24 MONTHS AFTER THE
SECOND TIME, AND PERMANENTLY AFTER THE THIRD TIME. A COURT CAN ALSO ORDER THE PERSON OFF
FOOD STAMP BENEFITS FOR AN ADDITIONAL 18 MONTHS.
THE PERSON CAN ALSO BE FINED UP TO
$250,000, SENT TO JAIL FOR UP TO 20 YEARS OR BOTH. UNDER OTHER FEDERAL LAWS, ADDITIONAL
CRIMINAL OR CIVIL ACTION MAY BE TAKEN AGAINST THE INDIVIDUAL.
FSP-922 (Rev. 5/10)
(Page 2)
DO NOT GIVE FALSE INFORMATION OR HIDE INFORMATION TO GET OR CONTINUE TO GET FOOD STAMP
BENEFITS.
DO NOT TRADE OR SELL FAMILIES FIRST CARDS.
DO NOT ALTER FAMILIES FIRST CARDS TO GET MORE FOOD STAMP BENEFITS THAN YOU SHOULD.
DO NOT USE SOMEONE ELSE'S FAMILIES FIRST CARD FOR YOUR HOUSEHOLD.
DO NOT USE FOOD STAMP BENEFITS TO BUY INELIGIBLE ITEMS SUCH AS ALCOHOLIC DRINKS AND
TOBACCO.
IF YOU OR ANY MEMBER OF YOUR HOUSEHOLD ARE CONVICTED IN ANY COURT OF TRADING YOUR FOOD
STAMP BENEFITS FOR FIREARMS, AMMUNITION, EXPLOSIVES OR CONTROLLED SUBSTANCES, THE GUILTY
PARTY WILL BE PERMANENTLY DISQUALIFIED FROM RECEIVING FOOD STAMP BENEFITS.
I UNDERSTAND THE PENALTY FOR HIDING OR GIVING FALSE INFORMATION. I ALSO UNDERSTAND I WILL
OWE THE VALUE OF ANY EXTRA FOOD STAMP BENEFITS I RECEIVE BECAUSE I HAVE NOT FULLY REPORTED
CHANGES IN MY HOUSEHOLD. I AGREE TO PROVE ANY CHANGES I REPORT IF YOU ASK. MY ANSWERS ON
THIS FORM ARE CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT MY
SIGNATURE AUTHORIZES FEDERAL, STATE, AND LOCAL OFFICIALS TO CONTACT OTHER PERSONS OR
ORGANIZATIONS TO VERIFY THE INFORMATION I HAVE PROVIDED.
YOUR SIGNATURE_____________________________
TODAY'S DATE _______________________
S:\WORKING\WFNJFORM\FSP-922.doc

Download Form FSP-922 Change Report Form for Food Stamp Non-simplified Reporting Cases - Burlington County, New Jersey

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