PURPOSE: Provides a written explanation of the changes in circumstances an applicant, recipient, or legal guardian of childcare benefits must report and the time frame for reporting. It advises the individual that failure to report or reporting false information may result in prosecution for fraud. An IM-3 signed by the individual certifies that s/he understands the reporting requirements and the consequences for failure to report.
NUMBER OF COPIES AND DISPOSITION: Make two copies. Give or mail a copy to the individual. File the original in the case file as a permanent part of the record.
NOTE: This form is used only for the Child Care Program.
MANUAL REFERENCE: Child Care Manual 1200.000.00 - 1240.000.00
INSTRUCTIONS FOR COMPLETION: Complete the form according to the type of interview conducted.
IN-PERSON INTERVIEW: At in-person interviews, the individual reads the form. Discuss the change reporting requirements with the individual during the interview. The eligibility specialist (ES) ensures the individual understands change reporting requirements. After discussing the reporting requirements, the individual signs and dates the form on the applicant's signature line. The ES signs the form and enters his/her telephone number.
TELEPHONE INTERVIEW: During a telephone interview, the ES discusses the information shown on the IM-3 form. The ES ensures the individual understands the change reporting requirements. After the telephone interview and discussion, the ES checks the box indicating the IM-3 was discussed with him/her and enters the date of the telephone interview. The ES signs the IM-3 and enters his/her telephone number. When the case is approved, the ES sends the copy of the IM-3 to the EU. The ES checks the box indicating the IM-3 was sent to the EU or legal guardian and the date it was sent.