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
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
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

Additional Changes
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.

Medicaid Changes Only
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:

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