FOOD DISTRIBUTION CHANGE REPORT FORM

FOOD DISTRIBUTION PROGRAM CHANGE REPORT FORM
P.O. Box 59

Watonga, OK 73772

(405)276-6049

Toll Free: (888)747-9520

Fax: (405)422-8261

Please use this form to report any of the following changes in your household:

REPORTING CHANGES: You are required to report changes in household size or composition; increases in gross monthly income of more than $100; changes in residence and/or address; when the household no longer incurs a shelter or utility expense; or a change in the legal obligation to pay child support to the Food Distribution Office within ten calendar days after the change become s known to the household. If you fail to report a change and, as a result, receive USDA foods that you were not entitled to, a claim will be filed against your household.
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
HOUSEHOLD MEMBERS
CHANGES IN HOUSEHOLD MEMBERS
INCOME OR CHANGE OF ADDRESS *
ADDITIONAL COMMENTS
Applicant's Signature *

Clear
Date

Month Day Year
Date
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex , religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http:// www.ascr.usda.gov!complaint filing cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)                   mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW

Washington, D.C. 20250-941 O;

(2)                   fax: (202) 690-7442; or

(3)                  email : program.intake @ usda.gov.

This institution is an equal opportunity provider.
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FOOD DISTRIBUTION PROGRAM CHANGE REPORT FORM

HOUSEHOLD MEMBERS