Effective Date: 

Effective Date: 3/2003


PDF: H0070.pdf



Updated: 3/2003


This form is an optional form for advisors to use to

  • provide food stamp streamlined reporting (SR) clients with an aid to determine if an income change must be reported, and
  • assist advisors in explaining the SR requirements.


When to Prepare

SR clients complete this form when the household's income has increased to calculate their monthly income to determine if they are required to report the increase.

Number of Copies

Advisors may provide SR clients several copies of the form, as needed.


Advisors give the forms to SR clients at the initial certification and each recertification. They may also attach the form to Form H1019, Report of Change.

Form Retention

There is no retention requirement.

Detailed Instructions

Steps 1 and 2 — Self-explanatory.

Step 3 — Advisors enter the household's food stamp gross income limit. This information is located in C-121, Maximum Income Limits Effective October 1, 2002. This information is also listed on the GenericWorksheet-produced Form H1009, TANF/Food Stamps Benefits Notice of Eligibility.

Step 4 — Self-explanatory.

Step 5 — Advisors must list the appropriate local or toll-free phone number for reporting changes.

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