Khác biệt giữa các bản “Thành viên:Nhiêu Lộc/Sandbox”

không có tóm lược sửa đổi
n
WOODBRIDGE OFFICE PRINCE WILLIAM DSS
Novant Health Prince William Medical Center
 
Case Name:
8700 Sudley Road, Manassas, VA 20110
 
15941 DONALD CURTIS DR, SUITE 180
STATEMENT
 
WOODBRIDGE, VA 22191
Patient Name:
 
Case Name:
Service Date: 12/02/14
 
Account Case Number: G00001277492
 
Worker #:
Thank you for your partial payment made on this account. This leaves $47.17 as your unpaid balance on this account.
 
Caseload #: 6682 Agency Telephone:(703)-792-5110
If you cannot pay the entire amount at once, please call us toll-free at (888) 891-7627 to make suitable arrangements or complete and return the form below.
 
Interim Report - Now Due
Please send your payments, made payable to Novant Health Prince William Medical Center, to the address noted above. Please use your account number on all payments and correspondence.
 
You must complete this report and return it to the address above no later than Sep 05, 2015 in order to continue to receive Supplemental Nutrition Assistance Program (SNAP) benefits.
If you wish to pay by Visa or Mastercard, complete the credit card information on the reverse side of this letter, tear off and return in the enclosed envelope. If you would like to discuss additional payment options or use other credit cards, please call our office toll-free at (888) 891-7627.
 
We will use the information on this form to see if you are still eligible for benefits or to determine the amount of your benefits. If you need help in filling out this form, please cad the telephone number listed above.
Thank you for your cooperation.
 
Please review the information taken from your application for benefits. Note if there have been any changes.
Novant Health Prince William Medical Center
 
Your case will close or your benefits will be delayed if you do not return this form completed. This means all sections must be answered. You must also send in proof for changes reported on Questions 4, 5, and 6.
I AGREE TO PAY $ EACH MONTH/WEEK STARTING ON
 
1. Address
Signature of responsible party
 
Mailing:
 
No Change
 
New Address:
 
Physical:
 
No Change
 
New Address:
Telephone Number:
 
No Change
 
New Number:
 
Answer this section only if you have moved and you listed a new address above
 
List your new shelter costs that are a result of the move. If you do not tell us about the expenses of your new home, you will not get a deduction for SNAP benefits.
 
Rent/Mortgage $
 
Electricity $
Gas/Oil $
 
Other $
Are you responsible for expenses for heating or for air conditioning of your new home?
 
Yes No
 
2. Household/Unit Members
 
No Change
 
Date Moved:
 
List information for any new people who have moved into your home.
 
Name:
 
Name.
Date of Birth:
sex: _
 
Relationship:
 
•Social Security Number:
 
(Social Security Numbers are used to check computer systems before new members may be added to the case)
 
 
 
3. Resources
 
Does the total amount of ail the cash, bank accounts, stocks, or bonds of everyone in your household go over $2,000?
 
Yes No
 
If yes, what is the amount?.
 
4. Child Support Obliaatfon
 
Has any household member had a change in the legal requirement to pay child support?
 
Yes No Not Applicable
 
If Yes, send proof.
 
5. Earned Income
 
No reported earned income
 
Have there been any changes in jobs for anyone in the household?
 
Yes No Not Applicable
 
Has anyone started or stopped a job?
 
If Yes, who?
 
New Employer
 
When?
 
What is the new income amount?
 
Yes No Not Applicable
 
If Yes, send proof.
 
Has the amount of Income from a job changed by $100 or more per month for anyone?
 
If Yes, for whom?
 
What is the new amount?
 
When?
 
Yes No Not Applicable
 
If Yes, send proof.
 
6. Unearned Income
 
SSI $733
 
Has the amount of Income from unemployment, pensions, disability, support, or other sources changed by more than $50?
 
Yes No Not Applicable
 
 
If Yes, for whom?
 
If Yes, send proof.
 
What is the new amount? Source
 
Has anyone started or stopped receiving income from unemployment, pensions, disability, support, or other sources?
 
If Yes, who?
 
What is the new amount? Source
 
Yes No Not Applicable
 
If Yes, send proof.
 
Is there any other information you want to share with us? If yes, please explain here.
 
I certify that the information given on this form is correct to the best of my knowledge. I am aware that if I provide false information. I will be breaking the law, and may have to repay any benefits received.
 
Signature of a Household Member or Authorized Representative
 
Date
 
Important Information - Please Read
 
Answer all the questions.
 
Be sure to sign and date the form.
 
Be sure to send proof if you answered "yes" for Questions 4,5, or 6.