Human Services P O

State of Illinois

Department of Human Services

TFTDFDADDDTATDTDFTAFDDTDDDTAFATFDTFTFDDFTFFTTTAAFAFAAAAADTFFAAFAA STEPHANIE BLANKENSHIP

PO BOX 472

TILDEN, IL 62292

Date of Notice: March 07, 2024

Case Number: 125467520

Client Name: STEPHANIE BLANKENSHIP

Individual ID: 118*******

Office Name: RANDOLPH COUNTY FCRC

Office Address: 870 LEHMEN DR

CHESTER, IL 62233

Phone: 618-***-****

TTY: 866-***-****

Fax: 844-***-****

You can manage your case online at abe.illinois.gov Esta notificación está disponible en Español. Usted puede solicitarla por Internet en abe.illinois.gov o llame al 1-800-***-**** (TTY 1-866-***-****)

Turn this page over to read more information on the back. VRS[85595215]

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SNAP MID-POINT REPORT

(Action Required)

Section A

You must complete, sign, and return this form by: Apr 2, 2024 There are several ways you can return this form to us: l Complete the electronic version available in the ABE Customer Portal/Manage My Case; or

l Complete, sign, and upload this form along with any requested verifications in the ABE Customer Portal/Manage My Case at abe.illinois.gov; or l Complete and sign the form and mail it to:

Data Preparation/IES Central Scanning

P.O Box 19138

Springfield, Illinois 62763

Section B

Please Read the Information Below

We need to know if there have been any changes in your household since your last report. We will use the information and proof that you give us to decide if you are still eligible for benefits. Your benefits may go up, down, or stop based on what you tell us. Your benefits will end Apr 30, 2024 if you do not complete, sign, and return this form. Our records show that these are your phone numbers. If not, tell us your correct numbers. Phone

Type

Current Phone Number New Phone Number Receive Text Alerts and Reminders*

(please check one)

Home o

Work

Cell 618-***-**** o

Alternate o

*Standard fees may apply from your mobile service provider. o I do not wish to receive text alerts and reminders. Tell Us About Changes in Your Address

1. Have you moved or changed your address? o No o Yes If #1 is yes, give us your new address and tell us about your housing and utility costs. Tell Us About Changes to Your Household/Assistance Unit 2. Has anyone moved into your home? o No o Yes

If #2 is yes, list the persons below and tell us their name, birthdate, Social Security Number, relationship and whether or not they eat and prepare meals with you. Tell Us About Changes to Your Household/Assistance Unit 3. Has anyone moved out of your home? o No o Yes

If #3 is yes, list the persons below.

Tell Us About Changes to the Child Support You Pay 4. Has there been a change in the legally -

obligated child support payments made by any

member of your household/assistance unit?

o No o Yes

If #4 is yes, who makes payments, how much and how often? VRS[85595215]

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Tell Us About Changes to Your Income From Work

5. Has the source of income or amount of

income changed by more than $125.00 from the

amount last used to calculate benefits for your

household/assistance unit?

o No o Yes

Instructions: For all households receiving TANF cash, read 5a. All other Non-TANF Households read 5b.

5a), If you receive TANF cash (even if you answered No to Number 5 above), attach copies of the last 4 pay stubs if paid weekly, last 2 pay stubs if paid every other week or twice a month, and the last pay stub if paid monthly. If your last pay stubs do not show the change, then tell us the name of the person who had a change in income from work, the new employer name, the new rate of pay, number of hours worked weekly, how often the person is paid, and date of last pay if his/her job ended.

5b) If #5 above is yes, attach copies of the last 4 pay stubs if paid weekly, last 2 pay stubs if paid every other week or twice a month, and the last pay stub if paid monthly. If your last pay stubs do not show the change, then tell us the name of the person who had change in income from work, the new employer name, the new rate of pay, numbers of hours worked weekly, how often the person is paid, and the date of last pay if his/her job ended. Tell Us About Changes to Your Other Income

6. Has there been a change in the source of

unearned income or the amount of unearned

income by more than $125.00 (excluding

changes in public assistance or general

assistance) such as legally - obligated child

support, social security, SSI, unemployment,

VA, worker's compensation, or contributions for

your household/assistance unit?

o No o Yes

If #6 is yes, tell us the name of the person who had a change of income, the type of income, the amount, and how often it is received.

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Tell Us About Changes to Your Lottery / Gambling Winnings 7. Has anyone in your household/assistance

unit received any money from Lottery /

Gambling Winnings of more than $4250.00?

o No o Yes

If #7 is yes, tell us the gross amount of lottery/gambling winnings before taxes. Attach proof documents.

Important for you to know:

l If we need more information, we will give you a notice that tells you what we need. You must return the information within 10 calendar days. If you do not do this, your benefits may be late or stop.

l SNAP households that include an able-bodied adult without dependents subject to the SNAP Work Requirement time-limit must report when work hours drop below 20 per week, averaged monthly.

l Call 1-800-***-****, or 1-866-***-**** TTY/Nextalk, 711 TTY Relay, if you need help or have questions with this form.

l Every person who receives SNAP benefits must follow these rules:

** Do not give false information to get, get extra, or continue to get SNAP benefits.

** Do not trade, steal, or sell SNAP benefits/Illinois LINK Card or resell food bought with SNAP benefits.

** Do not alter documents to get more SNAP benefits than you are entitled to receive.

** Do not use SNAP benefits to buy ineligible items, such as alcoholic beverages and tobacco.

** Do not use someone else's SNAP benefits or Illinois LINK card for your personal gain.

** Do not throw away beverages purchased with SNAP benefits to get money back from a container deposit.

Note: If you break the above rules on purpose, you can be barred from SNAP for twelve (12) months if it is your first violation, twenty-four (24) months for a second violation and permanently for a third violation.

Signature

By signing below, I swear or affirm, under penalty of perjury, the answers on this report form are true and correct to the best of my knowledge. I understand that the information I've provided may result in a reduction or termination of my benefits. Signature: Date:

Daytime or Cell Phone Number:

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Important Information

Ask your caseworker to explain anything you do not understand. Because the SNAP program requires a Social Security Number (SSN) for every member of your household who is applying for SNAP benefits, we are explaining how your SSN is used by DHS.

What does DHS do with your Social Security Number? The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we can help you apply for one. The SSN will be used in computer matching and program reviews or audits and to make sure the household is eligible for SNAP benefits, other Federal assistance programs, and Federally assisted state programs, such as school lunch, TANF, and Medicaid. DHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment. When Information does not match, we may contact a third party, such as employers, claims representatives or financial institutions to verify the information. This information may affect your eligibility for assistance and the amount of assistance provided. This may result in criminal or civil action or administrative claims against persons fraudulently participating in the SNAP program. We do not require a Social Security Number for any member of your household who is not eligible for the SNAP program or who does not wish to apply. Why does DHS collect your Social Security Number?

DHS will only use your SSN for the purpose for which it was collected. DHS will not: Sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number to be on documents mailed to you, or unless we are confirming the accuracy of your SSN.

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), 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-***-****.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling 833-***-****, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to: 1. mail:

Food and Nutrition Service, USDA

1320 Braddock Place, Room 334

Alexandria, VA 22314; or

Do not send applications or any forms to this address. 2. fax:

833-***-**** or 202-***-****; or

3. email:

************************@****.***

This institution is an equal opportunity provider. VRS[85595215] Turn this page over to read more information on the back. IL444-2890 (R-04-23) SNAP and TANF Mid-Point

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