Change Report For Employment Related Day Care (ERDC)

Branch: Case number: Worker ID:

Case name:

Change Report for Employment Related Day Care (ERDC)

Keep this form until you have a change to report. You must report changes within 10 days of the day they happen. You may call collect if needed.

What you must report for ERDC: 1. Increase in household monthly income at or Household size Gross monthly income above the amounts shown in this table; 2 $3,493 3 $4,315 2. Address change; 4 $5,137 3. Changing or adding a provider; 5 $5,998 4. Someone moves in or out, including a child, 6 $6,868 spouse, parent or parent of an unborn child; 7 $7,738 5. Someone is no longer working due to job loss 8 or above $8,610 or medical leave; 6. Employment during authorized work search or returning to an employer after medical leave; 7. If requesting child care while you are in school; 8. A discharged Military member returning from active duty in a war zone.

This form is to report changes for Employment Related Day Care (ERDC). If you are getting SNAP, cash or medical benefits, you will have other changes to report.

Changes can be reported by phone, mail or in person. If you mail or bring this form to a Department of Human Service (DHS) office, please complete the section below. New home address: New mailing address (if different than home address): New phone number: Current email (voluntary): My total household gross income is $ (do not report unless the amount is above the amount shown in the table above for your family size). (name) is no longer working due to job loss or medical leave Date last worked: (check one of the above) (name) started working during authorized work search or returned to work after medical leave.

Fill out this section for a person moving in or out of your household. Page 1 of 3 DHS 0862 (03/17) Person 1 Person 2 Someone moved: In Out In Out Date moved (in or out): Who moved: Birth date: Social Security number (voluntary for ERDC): Relationship to you: Sex:  Male Female  Male Female U.S. citizen? Yes No Yes No Needs child care? Yes No Yes No Person moving in has income? If Yes No Yes No yes, report it below and attach proof. Paid for working? (students: include Yes No Yes No work study): Check if self-employed Check if self-employed Employer’s name: Employer’s phone number: *Current hourly wage: *Current hours per week: *Tips per week: Work schedule (work hours and Hours work days): : Hours: Mon Tues Wed Thurs Mon Tues Wed Thurs

Fri Sat Sun Fri Sat Sun *Requires verification

Other income (not hours and work days); sources of other income are unemployment compensation, money for school, child support, workers’ compensation, money from family/friends, veteran’s benefits, Social Security/SSI, trusts and loans. Person 1 Person 2 Paid to: For whom: Source of income: How often paid: Applied for or getting now: Applied Getting Applied Getting Amount of each payment:

A new provider: This is my primary provider: Yes No Provider name: Date care began:

I am requesting childcare while attending school. Number of hours attending: Name of school: Type of course work: (i.e. online, classroom, vocational) Please attach proof of enrollment, class schedule and financial aid award letter. (Military member name) returned from active duty in a war zone. Date returned home:

of 3 DHS 0862 (03/17) By signing this form, I affirm under penalty of perjury I have given true and complete information. I realize that making false statements or hiding information may subject me to state and federal penalties. I have read this form and understand it. This is legally binding.

Full signature of primary person Date

Our non-discrimination policy The Department of Human Services (DHS) does not discriminate against anyone. This means that DHS will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.

You may file a complaint if you believe DHS treated you differently for any of these reasons.

To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at: Governor’s Advocacy Office 500 Summer Street NE, E17 Salem, OR 97301 Email: [email protected]

“Equal opportunity is the law!”

The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) are equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals with disabilities.

To file a complaint with USDA and HHS, please read the “Client Discrimination Complaint Information” form (DHS 9001). You can find this form in the “Information and Referral Packet” (DHS 6609).

1SNAP clients are protected against political belief discrimination. 2Sexual orientation is protected by the State of Oregon, but not federal laws.

of 3 DHS 0862 (03/17)