Alamance County Department of Social Services Change Form-Updated

Alamance County Department of Social Services Change Form
Please complete the information below.
Case Name: *
Name of Case Head
Enter the last four (4) digits of SSN:
Date of Birth:

MonthDayYear
Date
Phone Number:

Area CodePhone Number
Reported By:
Name of Individual Reporting the Change
Date*

MonthDayYear
Date
Household Services:
Which Services Does Your Household Receive? (Please select all that apply)

MedicaidFood Stamps (FNS)Work FirstChild Care
Please complete the appropriate section that pertains to your case change:
- CHANGE IN ADDRESS:
- Physical Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mailing Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Rent Amount:
- Land Lord Name & Number
- List all Household Members Moving to the new address:
- **IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE, WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?
  
  YesNo
- Change In Household
  
  SOMEONE MOVED INTO MY HOME: (INCLUDING NEWBORNS)
- Name
  
  First NameLast Name
- Date of Birth:
  
  MonthDayYear
  Date
- Enter the last four (4) digits of SSN:
- Relationship:
- IS THIS PERSON RECEIVING BENEFITS (FNS, MEDICAID, WFFA) IN ANOTHER STATE OR COUNTY?
  
  YesNo
- Move In Date:
- DOES THIS PERSON HAVE INCOME?
  
  YesNo
- Type of Income:
- Amount:
- SOMEONE MOVED OUT OF MY HOME:
- Name
  
  First NameLast Name
- Date of Birth:
  
  MonthDayYear
  Date
- Relationship:
- Where Did They Move to?
- Move Out Date
  
  MonthDayYear
  Date
- EARNED INCOME
- Has anyone stopped working? If Yes, please list the person(s) below:
  
  YesNo
- Person(s) Stopped Working
- Employer Name:
- Date of Last Pay
  
  MonthDayYear
  Date
- Pay Amount
- Has anyone started working? If Yes, please list the person(s) below:
  
  YesNo
- Person(s) Started Working
- Name of Employer
- Date of Hire:
  
  MonthDayYear
  Date
- Number of Hours Per Week
- Rate of Pay
- UNEARNED INCOME
- Person(s) Receiving
- Type of Income:
- Amount:
- Frequency:
- Date Received:
  
  MonthDayYear
  Date
- I am requesting (please select all that apply):
  
  Terminate my FNS (Food Stamps) CaseTerminate my Medicaid CaseNew EBT CardNew Medicaid CardOther
- Please list below the individuals you are requesting a new Medicaid card for. ***Please be aware that we can only issue a card if you are enrolled in NC Medicaid Direct. If you are enrolled in a Health Plan, you must contact them for a replacement card***
- Please list below the individuals you are requesting to have their Medicaid case terminated. I understand that we may still be eligible, however, I choose to terminate.
- Please list below the individuals you are requesting to have their Medicaid case terminated. I am moving to another state and want to apply for benefits or am receiving benefits there.
- Reporting Pregnancy
- Name of Pregnant Member:
- Estimated Due Date:
  
  MonthDayYear
  Date
- Requesting A New Primary Care Doctor
- Name:
- New Provider Or Practice:
- Tax Filing Questions
- Do you expect to file a tax return?
  
  YesNo
- If Yes, continue answering the questions below. If No, skip to question C.
- A. Will you file jointly with a spouse?
  
  YesNo
- If Yes, Name of Spouse
- B. Will you claim any dependents on your tax return?
  
  YesNo
- If Yes, Name(s) of Dependents:
- C, Will you be claimed as a tax dependent?
  
  YesNo
- If yes, Name of Tax Filer:
- Relationship to Tax Filer:
- Tax Filer's Income:
- Other Dependents:
- Evaluation of Current Medicaid Coverage
  
  Do you, your spouse, or children receive Family Planning Medicaid and need help paying medical bills during the last 3 months? If yes, provide medical bills or complete the following information.
- Who:
- Date of Services:
- Name of Hospital or Provider:
- Please evaluate the following individuals for Full Medicaid:
- If you change was not listed below, please explain your change below:
- Please sign below:*
- Date
  
  DayMonthYear
  Date
- Upload Documents Securely (HIPAA) Compliant
  
  Upload Document(s)
  Mobile Friendly Cancelof
- Please enter your email address below. If needed we will contact you for more information.
  example@example.com
- Should be Empty: