AVISO IMPORTANTE REFERENTE A SU CASO DE ASISTENCIA GENERAL

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1 BERGEN COUNTY BOARD OF SOCIAL SERVICES 216 STATE ROUTE 17 NORTH ROCHELLE PARK, NJ Tel. (201) FAX: (201) Internet: 8 AVISO IMPORTANTE REFERENTE A SU CASO DE ASISTENCIA GENERAL Su caso de Asistencia General será transferido a la Junta de Servicios Sociales del Condado de Bergen, situado en Passaic Street en Rochelle Park (216 Route 17, Edificio A), la misma oficina en la cual usted solicitó sus Cupones de Alimentos. Ya usted no tendra que visitar la oficina mensualmente. En vez de recibir su beneficio de Asistencia General en forma de cheque, los fondos serán depositados, el primer día de cada mes, en su tarjeta de EBT Familias Primero. Usted podrá utilizar dicha tarjeta para retirar su beneficio en efectivo en un cajero automático (ATM) en su vecindario. Adjunto están las instrucciones y una lista de ATM's en su área que aceptan la tarjeta EBT Familias Primero. Si usted no tiene una tarjeta de EBT Familias Primero, por favor comuniquese con nuestra oficina. Su Asistencia General se convertirá automáticamente a su tarjeta de EBT Familias Primero. No es necesario llamar o visitar a nuestra oficina a menos que usted tenga que reportar un cambio de circunstancias. Para reportar un cambio en las circunstancias: Complete el formulario adjunto y envíelo a esta agencia por correo o fax. Visite para obtener copias adicionales del formulario para reportar un cambio. Visite nuestra oficina en persona Asistencia de Emergencia de Renta. Si usted recibe asistencia de emergencia para la Renta, el pago seguirá siendo enviado al dueño por correo. Hackensack GA Transfer Unit

2 LISTA DE ATM S EN HACKENSACK Bank of America 360 Essex Street Hackensack Chase Bank 370 Essex Street Hackensack Costco 80 S. River Street Hackensack CVS/Sovereign Bank 110 Main Street Hackensack CVS/Sovereign Bank 101 Polifly Road Hackensack Lakeland Bank 235 Main Street Hackensack North Fork Bank 450 Hackensack Avenue Hackensack Mariner s Bank 240 Essex Street Hackensack Oritani Bank 321 Main Street Hackensack Oritani Bank 1 Spring Valley Road Hackensack PNC Bank 113 Main Street Hackensack PNC Bank/Stop & Shop 380 W Pleasantview Ave Hackensack PNC Bank 409 Route 17 Hackensack Provident Bank 160 Prospect Avenue Hackensack TD Banknorth 77 River Street Hackensack TD Banknorth 111 River Street Hackensack Valley National Bank 111 Hackensack Ave Hackensack Valley National Bank 20 Court Street Hackensack Wells Fargo Bank 1 Johnson Avenue Hackensack Wells Fargo Bank 239 Main Street Hackensack

3 Instructions Please complete this form when reporting any change in circumstances including but not limited to: employment, income, address, household composition. You must always provide the following information on the form: 1. Your Name 2. Your Case Number 3. Your Daytime Telephone Number For a change in employment you must also provide: 1. All Information requested in the Change in Employment Section and 2. Four pay stubs or letter from employer* For a change in income you must also provide: 1. All Information requested in the Change in Income Section and 2. Proof of new weekly or monthly amount* For a change of address you must also provide: 1. All Information requested in the Change of Address Section and 2. A copy of the lease, rent receipt, and all pages of PSE&G or Orange & Electric bill* For a change in household composition you must also provide: 1. All Information requested in the Change in Household Composition Section and 2. A copy of the birth certificate and Social Security Card, if applicable* You may return the form and required documents by: Fax: Mail or in Person: 216 State Road 17, Rochelle Park, NJ *You must provide the required documentation to the Board of Social Services at the time you are requesting the change. If you fail to provide the required documentation, the Change Request will not be processed.

4 BERGEN COUNTY BOARD OF SOCIAL SERVICES 216 STATE ROUTE 17 NORTH ROCHELLE PARK, NJ REPORTING CHANGES IN CIRCUMSTANCES Use this form to report changes in circumstances for you and your family. Your Name, Case Number & Daytime Phone Return by Mail To: Name Bergen County Board of Social Services Case Number 216 State Hwy 17 Daytime Phone No. Rochelle Park, NJ Print Postage-Paid #10 Envelope Return by FAX: Change in Employment: Provide 4 pay-stubs or a letter from your employer. Start Of New Job / Person Employed Amt. / Wk. Date of 1 st Pay Employer Name Job Ended / Person who Lost Job Date of Last Pay Reason for Leaving Change in Income Earned or Unearned (unemployment, child support, Social Security or SSI): Provide proof of weekly or monthly amount. Income Name of Person Amt Wk Mo New Increase Decrease Earnings Wk Mo Unemployment Wk Mo Child Support Wk Mo Social Security Disability Wk Mo Social Security SSI Wk Mo Pension Wk Mo Other/Type: Wk Mo Change of Address: Provide a copy of lease, rent receipt and all pages of utility bill. NEW ADDRESS: Street Apt City / State Zip Do you pay for cost of heating? Yes No Do you pay for the cost of air conditioning? Yes No If yes, what type of heating? How much is your monthly rent? $ / mo Change in Household Composition: Baby born or other persons added to or leaving your household. Provide birth certificate or alien resident card and social security card and poroof of income. Name of Person DOB SSN Income Type Amt 1. Yes No $ 2. Yes No $ 3. Yes No $ Other Changes: Please explain below and provide verification. Web; Change in Circumstances Report Rev: 3/15/13/ds

5 NJ SNAP-922A (Rev. 10/13) CASEWORKER: CASE BANKING PHONE NO. FAX NO. (201) CASE NO.: CASE NAME: DATE: NEW JERSEY SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (NJ SNAP) CLIENTS NPA Simplified Reporting Requirements for Expanded Categorical Eligible Households at 185% of the Federal Poverty Level (FPL) This is to notify you that, because you are now on simplified reporting, the only change you are required to report is a change in total monthly household income when that total income is greater than the amount listed in the table below. To determine your household/cash assistance unit s total monthly income, add the gross amount (the amount of the income before deductions are taken out) of the earned income to any unearned income such as Social Security Benefits or other cash assistance that is received by you during the month. If the total amount of your household/cash assistance unit s income is greater than the amount shown below for the number of persons you receive NJ SNAP benefits for, you must report that total income to us within 10 days of the date you become aware of the change. Although you are not required to report changes until you receive your interim reporting form, it may be to your advantage to report a change if you lose your job or someone joins your household since your benefits may increase in these situations. Number of persons receiving Total Gross Income is greater than: receiving food stamps: Monthly Twice a month Bi-weekly Weekly 1 $1,772 $886 $818 $409 2 $2,392 $1,196 $1,104 $552 3 $3,011 $1,506 $1,389 $695 4 $3,631 $1,816 $1,676 $838 5 $4,251 $2,126 $1,962 $981 6 $4,871 $2,436 $2,248 $1,124 7 $5,490 $2,745 $2,533 $1,267 8 $6,110 $3,055 $2,820 $1,410 Each Additional Member Add: $620 $310 $286 $143

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