MO HealthNet Participants: Reported changes will not affect eligibility for children ages 18 and under during their 12 month eligibility period. To learn more, read the FAQs.

 

 

Report a Change

Report changes for your household

Report any changes for your household on this form. Reporting a new address, mailing address, phone number, or email address means that Family Support Division (FSD) can reach you to send important information. Other changes are required depending on what FSD benefits you are receiving.

Supplemental Nutrition Assistance Program (SNAP) participants must report if:

  • Your income exceeds the limit for your household size. See Maximum Allowable Income Limits. 
  • You have substantial lottery or gambling winnings (if you win more than $4,250 in a single game).
  • Your work hours decrease and you are subject to Able-Bodied Adults Without Dependents (ABAWD) work requirements.

Temporary Assistance (TA) and MO HealthNet (MHN) participants must report if:

  • Your income changes.
  • Anyone moves in or out of your house.
  • Assets exceed the limit for TA or for MO HealthNet for the Aged, Blind, and Disabled.

You do not have to fill out the whole form, only what changed for you. You may also call FSD at 855-373-4636, or visit any FSD office.

NAME:

or

Address and contact information

Current Mailing Address (Street, City, State, Zip Code)

Current Home Address (Street, City, State, Zip Code) If you do not have a home address, include the city, state, zip code where you stay.

Please list the expenses you have now:

Rent

Phone

Water

Sewer

Trash

List the expenses you have now cont:

Mortgage

Real Estate Taxes (if not included in mortgage)

Home Insurance (if not included in mortgage)

Electric

Is this used for

Gas/Propane

Is this used for

Other

Is this used for

Were there changes to your assets?

Include changes in money or accounts, lottery or gambling winnings, and any sales or purchase of any assets (like vehicles or property).

Do you need to close your FSD case for the household, or end benefits for some household members?

Close

Do you need to add someone to your FSD benefits?

List anyone you wish to request benefits for, such as a new household member, someone who was not previously included in your FSD benefits, or someone who purchases & prepares food with you (for SNAP)

*SOCIAL SECURITY NUMBERS (SSN) - You must provide the SSN of all persons applying for or receiving SNAP, TA or MHN 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),

Benefits

For FASTER service: For each person you want to add or change, also complete a MO HealthNet Addition (IM-1ADP).

For any person who is over 65 years, blind, or disabled, complete an Aged, Blind, and Disabled Supplement (IM-1ABDS).

For MHN and TA cases, if any new household member is a minor child with a parent not living in the home, we will need to explore if that parent is responsible for financial support for the child. Good Cause can be claimed if you believe exploring support could cause physical harm or emotional harm to the child or to yourself. You will be asked to provide proof to support your good cause claim.

If no, FSD will be requesting additional information about the child’s parent who lives outside of the home.

Were there changes to your household's income?

This could include pay from a job, tips, or self-employment, and also other income such as Social Security, Supplemental Security Income (SSI), veteran’s benefits, child support, or alimony.

Were there changes for child support you pay?
Were there changes for your health insurance?
Were there changes to your dependent care provider? Or the amount you pay?
Were there other changes you need to report?
Sign and Submit

FOR SNAP - If you purposely hold back information about changes in your household, you will owe us the value of the extra benefits you receive 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.

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

For all programs - By signing this document, I certify under penalty of perjury that all declarations made in this document are true, accurate, and complete, to the best of my knowledge. Electronic Signature Terms and Conditions: I have agreed to sign this document by electronic means. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

    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