MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

CHANGE REPORT
Submitted FORM ID: 6605420063
Report any changes for your household on this form. Reporting a new address, mailing address, phone number, or email
address means that Family Support Division (FSD) can reach you to send important information. Other changes are
required depending on what FSD benefits you are receiving.

Supplemental Nutrition Assistance Program (SNAP) participants must report if:

• Your income exceeds the limit for your household size. See Maximum Allowable Income Limits.
• You have substantial lottery or gambling winnings (if you win more than $4,250 in a single game).
• Your work hours decrease and you are subject to Able-Bodied Adults Without Dependents (ABAWD) work requirements.

Temporary Assistance (TA) and MO HealthNet (MHN) participants must report if:
• Your income changes.
• Anyone moves in or out of your house.
• Assets exceed the limit for TA or for MO HealthNet for the Aged, Blind, and Disabled.
You do not have to fill out the whole form, only what changed for you. You may also visit myDSS.mo.gov, call FSD at
855-373-4636, or visit any FSD office.
Name DCN SSN Date of birth
Viola Ianniello 130-62-1903 11/23/1966
Email address Phone number Does this phone receive text Secondary phone number
[email protected] (816) 493-1358 messages? Yes No
Current Mailing Address (Street, City, State, Zip Code)
1300 SOUTH 11TH STREET, 339, SAINT JOSEPH, Missouri, 64503
Current Home Address (Street, City, State, Zip Code) If you do not have a home address, include the city, state, zip code where you
stay.
1300 SOUTH 11TH STREET, 339, SAINT JOSEPH, Missouri, 64503
List everyone in YOUR household living at this address.
Only me Viola Ianniello
List any other people living at this address, besides your household. For example, roommates or any other family
members who you are not responsible for (grandparents, cousins, etc.).
0
Did you move?
When did you move? Are you a boarder? Yes No
Please list the expenses you have now:
Expense Type Monthly amount Who pays? Expense Type Monthly amount Who pays?

Rent $888.00 I do...Viola ianniello Mortgage

Phone $52.00 I do...Viola Ianniello Real Estate Taxes (if not
Water included in mortgage)
Sewer Home Insurance (if not
Trash included in mortgage)
Electric $188.00 Viola ianniello Is this used for ✖ Heating? ✖ Cooling?
Gas/Propane Is this used for Heating? Cooling?
Other Is this used for Heating? Cooling?
Were there changes to your assets?
Include changes in money or accounts, lottery or gambling winnings, and any sales or purchase of any assets (like vehicles or property).
Type of Change Name Explain what changed New amount Date of change
Start
Stop Viola Ianniello SsD $1,439.00 06/12/2023
Amount

Submitted Date Time: 06/12/2023 4:36:20 PM Page 1 of 3 IM-145 CHANGE REPORT (2/2023)
Do you need to close your FSD case for the household, or end benefits for some household members?
I want to close all of my FSD cases immediately for all household members.
I want to close only this benefit type immediately, for all household members. Close SNAP MHN TA CC
I want to end all benefits for some household members, listed below.
Household members names:
Do you need to add someone to your FSD benefits? List anyone you wish to request benefits for, such as a new household
member, someone who was not previously included in your FSD benefits, or someone who purchases & prepares food with you (for SNAP).
Name Relationship to you Date of birth SSN* Disabled? Benefits
Yes SNAP TA
No MHN CC
*SOCIAL SECURITY NUMBERS (SSN) - You must provide the SSN of all persons applying for or receiving SNAP, TA or MHN as a condition of eligibility. The SSN will be used to determine eligibility
and level of benefits, verify information, prevent duplicate issuances, and to facilitate mass changes in Federal benefits (FS Act of 1977 & Public Law 97-98).
If you have an active MHN case, do you want to explore new benefits or a different kind of MHN for someone (such as pregnancy)?
If yes, who?
For FASTER service: For each person you want to add or change, also complete a MO HealthNet Addition (IM-1ADP).
For any person who is over 65 years, blind, or disabled, complete an Aged, Blind, and Disabled Supplement (IM-1ABDS).
For MHN and TA cases, if any new household member is a minor child with a parent living outside of the home, we will need to
explore if the parent outside of the home is responsible for financial support for the child. You may claim to have good cause for
refusing to provide information for the parent outside of the home if you believe it would not be in the best interest of you or your
child(ren). You must provide evidence to support this good cause claim.
Would you like to claim good cause? Yes No
If yes, please explain your good cause reason:
If no, FSD will be requesting additional information about the child’s parent who lives outside of the home.
Were there changes to your household’s income?
This could include pay from a job, tips, or self-employment, and also other income such as Social Security, Supplemental Security
Income (SSI), veteran’s benefits, child support, or alimony.
Who do you receive the
Change Name New amount Per Hours per week Date
income from?
Start Hour Week
Stop Viola Ianniello Ssa $1,439.00 2 wks 2x/mth
Amount Mth Year
Were there changes for child support you pay?
Change Name Dependent's name Is the child support court ordered? New amount Date
Start
Stop
Amount
Were there changes for your health insurance?
Who was/is covered by
Change Name Insurance Company Name New amount Date
this policy?
Start
Stop
Amount
Were there changes to your dependent care provider? Or the amount you pay?
Provider's Number
Dependent's Name Provider's Name How often is it paid? New amount Date
(optional)

Were there other changes you need to report? This could include changes for medical expenses, a divorce or marriage,
or any other change not already reported.

Will the reported change(s) be for more than one month? Yes No

Submitted Date Time: 06/12/2023 4:36:20 PM Page 2 of 3 IM-145 CHANGE REPORT (2/2023)
FOR SNAP - If you purposely hold back information about changes in your household, you will owe us the value of the extra benefits you receive a result. You may also be barred from the SNAP
program for 1 year, 2 years, or permanently and be fined and/or imprisoned.
PENALTY WARNING: Any information provided on this form is subject to verification by federal, state, and local officials. If any information is inaccurate, you may be denied SNAP benefits and/or be
subject to criminal prosecution for knowingly providing false information.
• 13 CSR 40-2.190 provides for recovery of benefits when it is determined someone has received benefits they are not entitled to.
• 7 USC 2024(b)(c) and (h). Anyone who knowingly uses, transfers, acquires, alters, or possesses coupons, or access devices in any manner contrary to the SNAP is subject to fine and
imprisonment. Upon conviction, punishments include a fine of $250,000 and/or imprisonment for 20 years if the value of the coupons or access devices is $5,000 or more. If the value is
less than $5,000 but greater than $100, punishments include a fine of $10,000 and/or imprisonment for 5 years. If the value is less than $100, punishments include a fine of $1,000 and/or
imprisonment for 1 year. Anyone who presents for payment or redemption coupons which have been illegally received, transferred, or used is subject to a fine of $20,000 and/or
imprisonment for 5 years if the value of the coupons is $100 or more. If the value is less than $100, punishments include a fine of $1,000 and/or imprisonment for 1 year. Anyone convicted
of felony offenses relating to the above transactions is also subject to having all real and personal property used in such transactions forfeited to the United States.
• 7 USC 2015(b)(1). Anyone convicted in a federal, state, or local court of trading benefits for controlled substances, illegal drugs or certain drugs for which a doctor's prescription is
required, shall be barred from the SNAP for 2 years for the first offense and permanently for the second offense. Anyone convicted of trading benefits for firearms, ammunition, or
explosives is barred permanently from the SNAP for the first offense.
• 7 USC 2015(b)(1)(iii)(IV) and 2015 (j). Anyone convicted of trafficking in SNAP benefits of $500.00 or more shall be permanently disqualified from the SNAP program for the first offense.
Anyone found by a state agency to have made or convicted in a federal or state court of having made fraudulent statements about identity or residence in order to receive multiple SNAP
benefits simultaneously shall be ineligible to participate in the SNAP for ten (10) years beginning with the date of such agency determination or such conviction in a federal or state court.
FOR ALL PROGRAMS EXCEPT MO HEALTHNET- I understand I will owe the value of any extra benefits I receive because I do not fully report changes in my household. I understand the penalty for
hiding or giving false information. My signature below certifies under the penalty of perjury that all declarations made on this change report are true, accurate, and complete.
For all programs - By signing this document, I certify under penalty of perjury that all declarations made in this document are true, accurate, and complete, to the best of my knowledge. Electronic
Signature Terms and Conditions: I have agreed to sign this document by electronic means. I understand that an electronic signature has the same legal effect and can be enforced in the same way as
a written signature. I agree.
Participant Signature Date
Viola Ianniello 06/12/2023

Submitted Date Time: 06/12/2023 4:36:20 PM Page 3 of 3 IM-145 CHANGE REPORT (2/2023)