M E M O R A N D U M

IM-222 12/18/01  FORMS MANUAL REVISION #38
IM-101, IM-112, IM-145B, AND IM-149


SUBJECT:
FORMS MANUAL REVISION #38
IM-101, IM-112, IM-145B, and IM-149
 
DISCUSSION:
The IM-101, Household Member Age 16-60 Assessment; IM-112, Action Taken on Your Food Stamp Case; and the IM-149, Household Notification of Benefit Adjustment forms are revised.  A new change report form, IM-145B Change Report, is created for use by earned income households to report changes in income. 

IM-101

The reference to JTPA (Job Training Partnership Act) is changed to WIA (Workforce Investment Act).  The JTPA Program no longer exists and has been replaced with WIA. 

IM-112

The IM-112 is reformatted and changed as follows: 

  • a statement is added to notify earned income households of the household's income maximum and the need to report if total income exceeds that amount, 
  • a statement notifying the household an interview must be completed before eligibility can be determined is added, and
  • a statement is added to notify the household, if it changes from a household without earned income to an earned income household, its certification period may be changed without prior notice.
IM-149

The IM-149 is also reformatted.  Statements are added to notify the household: 

  • their certification period is changed and
  • there is a change in the household's reporting requirement. 
The IM-149 (EBT) is obsolete.  Remove the IM-149 (EBT) and instructions from the Forms Manual.

Change Report Form for Earned Income Households 

The IM-145B Change Report is created for use by earned income households to report income changes.  Provide the IM-145B to households:

  • subject to the earned income reporting requirement upon approval for benefits, 
  •  when adjusting benefits, and
  • whose reporting requirement changes to the earned income reporting requirement during their certification. 
Continue using the current IM-145 for all other households.

Use current forms until depletion making changes to the IM-112 and IM-149 as outlined in memorandum IM-#76.

 
NECESSARY ACTION:
  • Review this memorandum with appropriate staff.
  • Begin providing the new IM-145B to earned income households at approval and change in circumstances.
  • Use current forms until depletion making changes to the IM-112 and IM-149 as outlined in    memorandum IM-#76.
  • Dispose of the current supply of the IM-149 (EBT). 
JKW
Distribution #6
Forms not available online, hard copy only
IM-112 (pages 1-5) and IM-149 (pages 1-3) instructions (Adobe Acrobat)
IM-145B instructions (Adobe Acrobat)

[ Memorandum Table of Contents ]

IM-221
IM-223