Report a Change

Report Changes for Your Household

If your household circumstances change, Federal law requires you report the changes to Family Support Division with ten (10) days. You may report your changes on this form. You may also call FSD at 855-373-4636 or visit an FSD office.

You must complete “Report Changes for Your Household” and “Sign & Submit". 

You can navigate to each of the sections to provide information that has changed. You do not have to complete every section if there were no changes.


New Household Members

If you have new household members, provide their information here. If there is more than 1 new household member, click the plus (+) to add additional household members. 

You must provide the Social Security Number (SSN) of all persons applying for or receiving SNAP as a condition of eligibility. The SSN will be used to determine eligibility and level of benefits, verify information, prevent duplicate issuances, and to facilitate mass changes in Federal benefits (FS Act of 1977 & Public Law 97-98). 


Household Members Left

If you have household members who have moved out, provide their information here. If there is more than 1 household member who has moved out, click the plus (+) to name additional household members. 

 

B.    Household Members No Longer Living With You


C.    Change In Income (Attach Verification For Temporary Assistance And SNAP)

Earned Income: (Earned income includes wages, salaries and income from self-employment)

For Both Temporary Assistance And SNAP, You Must Report The Following Changes:

  • Any changes in the source of any type of earned income for any household member.
  • Any changes in the base rate of pay for any employed household member.
  • Any change in the number of hours worked that is expected to continue for any employed household member
  • If you become employed or if you lose your job.

Unearned Income: (Unearned income includes Social Security, Supplemental Security Income (SSI), veterans benefits, child support, alimony, etc.)

For SNAP, You Must Report:

  • Any changes of more than $25 in unearned income.

For Temporary Assistance, You Must Report:

  • Any changes in unearned income (You do not have to report your Temporary Assistance check)

D.    Changes Of Vehicles Or Car (Includes Boats, Trailers, Recreation Vehicles, Snowmobiles, Etc.)


E.    Increase In Case Savings, Stocks, Bonds, Checking Accounts, Etc.

HOW MUCH DOES YOUR HOUSEHOLD NOW HAVE IN CASH/SAVINGS? (FOR SNAP, YOU MUST REPORT WHEN YOUR RESOURCES EXCEED THE PROGRAM LIMIT.) (FOR TEMPORARY ASSISTANCE, YOU MUST REPORT ALL CHANGES IN RESOURCES.)

F.    If You Have Moved

G.    Change In Rent, Mortgage, Or Utilities (Gas, Electricity, Oil, Etc.) SNAP Only

If you have moved, place a check (x) mark in the appropriate boxes for expenses you have at the new residence.

H.     Change In Dependent Care Costs (Attach Verification) Optional for SNAP and MHN


I. Child Support Expense  List any legally binding child support paid to NON-HOUSEHOLD members (includes current payments, arrearages, and health insurance).


J.  For Temporary Assistance, Please Provide Any Information That Has Changed Or Was Not Previously Reported On the Absent Parent

K.  Other - Please Report Any Other Changes Here Examples: Change in medical insurance or coverage, a marriage or divorce, ownership of property, etc (Optional if SNAP only)

L.    Will The Change(s) Be For More Than One Month?

IF YOU PURPOSELY HOLD BACK INFORMATION ABOUT CHANGES IN YOUR HOUSEHOLD, YOU WILL OWE US THE VALUE OF EXTRA BENEFITS YOU RECEIVE AS A RESULT. YOU MAY ALSO BE BARRED FROM THE SNAP PROGRAM FOR 1 YEAR, 2 YEARS, OR PERMANENTLY AND BE FINED, AND/OR IMPRISONED.

PENALTY WARNING: Any information provided on this form is subject to verification by federal, state, and local officials. If any information is inaccurate, you may be denied SNAP benefits and/or be subject to criminal prosecution for knowingly providing false information.

13 CSR 40-2.190 provides for recovery of benefits when it is determined someone has received benefits they are not entitled to.

7 USC 2024(b)(c) and (h). Anyone who knowingly uses, transfers, acquires, alters, or possesses coupons, or access devices in any manner contrary to the SNAP is subject to fine and imprisonment. Upon conviction, punishments include a fine of $250,000 and/or imprisonment for 20 years if the value of the coupons or access devices is $5,000 or more. If the value is less than $5,000 but greater than $100, punishments include a fine of $10,000 and/or imprisonment for 5 years. If the value is less than $100, punishments include a fine of $1,000 and/or imprisonment for 1 year. Anyone who presents for payment or redemption coupons which have been illegally received, transferred, or used is subject to a fine of $20,000 and/or imprisonment for 5 years if the value of the coupons is $100 or more. If the value is less than $100, punishments include a fine of $1,000 and/or imprisonment for 1 year. Anyone convicted of felony offenses relating to the above transactions is also subject to having all real and personal property used in such transactions forfeited to the United States.

7 USC 2015(b)(1). Anyone convicted in a federal, state, or local court of trading benefits for controlled substances, illegal drugs or certain drugs for which a doctor's prescription is required, shall be barred from the SNAP for 2 years for the first offense and permanently for the second offense. Anyone convicted of trading benefits for firearms, ammunition, or explosives is barred permanently from the SNAP for the first offense.

7 USC 2015(b)(1)(iii)(IV) and 2015 (j). Anyone convicted of trafficking in SNAP benefits of $500.00 or more shall be permanently disqualified from the SNAP program for the first offense. Anyone found by a state agency to have made or convicted in a federal or state court of having made fraudulent statements about identity or residence in order to receive multiple SNAP benefits simultaneously shall be ineligible to participate in the SNAP for ten (10) years beginning with the date of such agency determination or such conviction in a federal or state court.

I understand the penalty for hiding or giving false information. I also understand I will owe the value of any extra benefits I receive because I do not fully report changes in my household. My signature below certifies under the penalty of perjury that all declarations made on this change report are true, accurate, and complete.

    Thank You

    Dear {formsubmittinguser},

    Thank you for reporting your household changes. Your request has been sent to the Family Support Division (FSD) for review. You will be notified when we have completed our review. FSD may contact you if additional information is needed to process your change request.

    The information below may be needed prior to processing your change request.

    • Income verification for the past 30 days (i.e. paycheck stubs, letter from employer, federal income tax return, award letter, etc.);
    • Proof of U.S. citizenship, or if not a U.S. citizen, immigration documents showing name, immigration status, registration number and date of entry for those persons applying for MO HealthNet who are not U.S. citizens;
    • Medical statement confirming pregnancy and expected date of delivery (if applying for MO HealthNet as a pregnant woman).

    If you do not have the above documents, we may be able to help you.

    If you have questions or want to check on the status of your change report, you may call the FSD Information Center at 855-FSD-INFO (855-373-4636). Your change request number is {formuniqueid}.

    If you would like to print or save a copy of your change report for your files, click the Print button below. If you decide to print or save, keep in mind that your Change Report has your private and personal information in it.

    Sincerely,
    Family Support Division