The ES 3114 Kansas form is an important document used by the Department for Children and Families to assess ongoing eligibility for food assistance. This interim report form gathers essential information about changes in your household, income, and other relevant factors. Completing this form accurately ensures that you continue to receive the support you need.
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The ES 3114 Kansas form is an essential document for individuals and families seeking to maintain their eligibility for food assistance through the Kansas Department for Children and Families. This interim report form serves as a crucial checkpoint, requiring recipients to provide updated information regarding their household circumstances. Key areas of inquiry include any changes in household composition, such as people moving in or out, as well as employment status for all working members. The form also asks about changes in income, including child support and other benefits, ensuring that the Department has the most current financial picture. Additionally, it inquires about cash on hand and assets, which can affect eligibility. Recipients must complete the form and return it promptly to avoid the closure of their food assistance case. The form emphasizes the importance of accuracy, as any discrepancies or failure to report changes can lead to serious consequences, including potential fraud charges. For those needing assistance, local DCF offices and a dedicated hotline are available to provide support in navigating the reporting process.
Completing the ES 3114 Kansas form is an important step in ensuring that your eligibility for food assistance is accurately assessed. It is essential to provide truthful and complete information, as any discrepancies could affect your benefits. Below are the steps to fill out the form effectively.
After completing the form, it is crucial to return it by the specified deadline. Failure to do so may result in the closure of your food assistance case. If you have any questions or need assistance while filling out the form, do not hesitate to reach out to your local DCF office or call the provided helpline.
When filling out the ES 3114 Kansas form, it's important to be thorough and accurate. Here’s a list of things you should and shouldn't do:
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STATE OF KANSAS
DEPARTMENT FOR CHILDREN AND FAMILIES
ECONOMIC & EMPLOYMENT SERVICES
ES-3114 10-14
FOOD ASSISTANCE INTERIM REPORT FORM
Name:
Case Number:
Address:
City, State, Zip:
We need the following information to determine if you are still eligible for food assistance. Please complete this form and return it to us by___________________________________________________.
If you do not complete and return this form your food assistance case will close
________________________.
Use extra paper if needed to answer all the questions.
This action is based on Kansas Economic and Employment Services Manual Sections 9122 and 9372.
If you have questions or need help completing the interim report form, contact your local DCF office or call 1-888-369-4777.
1.
Have any persons moved in or out of your home since you last reported? No
Yes
If yes, list the name and date of birth and mark whether they moved in or moved out of your home
below.
Name
Date of Birth
___________ _______________ (check one) Moved In
Moved Out
2.For all persons in your home who are working, answer the following questions:
a. Has anyone changed employers since last reported? No
If yes, enter name__________________ and complete the following. If no, go to item b below.
Name of Employer___________________________________Phone Number____________
Hours Worked Per Week_________________Hourly Rate or Salary____________________
Day of Week Paid______________ How Often Paid_________Date of First Pay__________
If anyone has changed employers, please provide the most recent 30 days of paystubs.
b. If anyone is still with the same employer, has there been a change in the wage rate, salary, or
full-time or part-time employment status since you last reported? No
If yes, enter name________________________________ and complete the following:
Hours Worked Per Week___________________ Hourly Rate or Salary__________________
Explain:____________________________________________________________________
If the income has changed, please provide the most recent 30 days of paystubs.
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3.
Has anyone started a job since last reported? No
If yes, enter name______________________________________ and complete the following:
Name of Employer_________________________________Phone Number_________________
Hours Worked Per Week_________________Hourly Rate or Salary_______________________
Day of Week Paid______________ How Often Paid_________Date of First Pay_____________
If anyone has started a job, please provide the most recent 30 days of paystubs.
4.
Has anyone stopped a job since last reported? No
If yes, explain:_________________________________________________________________
5.For all persons in your home that are getting other income (child support, Social Security, SSI,
VA, Unemployment Benefits, etc.), has that income changed by more than $50? No Yes If yes, explain:_________________________________________________________________
6.Has the amount of cash on hand, stocks, bonds or money in a bank account or savings institution
reached or gone over $2,250? No
If yes, explain: _________________________________________________________________
7.Have you moved? No Yes
If yes, answer the following questions:
a.Your new address:___________________________________________________________
b.Date moved:________________________________________________________________
c.Landlord name, address and phone______________________________________________
__________________________________________________________________________
d.Rent/mortgage amount:_______________________________________________________
e.Property taxes not included in mortgage (if applicable)_______________________________
f.Homeowners insurance not included in mortgage (if applicable)________________________
g. Do you pay for heating or cooling at your new address? No Yes
8.For all persons in your home that have a legal obligation to pay child support, have there been
any changes in the legal obligation to pay child support (court ordered amount increased or decreased)? No Yes
_____________________________________________________________________________
If yes, please provide proof of the change in your legal obligation to pay child support.
9.List any other information you would like DCF to know:_________________________________
10.Signature and Date:
I UNDERSTAND THE QUESTIONS ON THIS FORM, AND I CERTIFY, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN BY ME ON THIS FORM IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I also understand that any changes reported on this form may result in a reduction or termination of benefits. I also understand that if I am found guilty of fraud I may not get food assistance for one year for the first offense, two years for the second offense and permanently for the third offense. SIGNATURE___________________________________DATE___________________________
TELEPHONE NUMBER WHERE YOU CAN BE REACHED______________________________
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Here are some common misconceptions about the ES 3114 Kansas form:
Many people believe that completing the ES 3114 form is optional. In reality, it is required to determine continued eligibility for food assistance. If you do not submit it, your case may close.
Some individuals think that only changes in income matter. However, any changes in household composition, such as someone moving in or out, must also be reported. This includes changes in employment status and any legal obligations like child support.
People often assume they can submit the form whenever they want. It’s important to return the form by the specified deadline to avoid losing benefits. Timeliness is key to maintaining your assistance.
Some may feel overwhelmed by the form and think it's too complicated. In reality, it’s designed to be straightforward. If you have questions or need help, you can reach out to your local DCF office or call the provided hotline for assistance.
The ES-3114 Kansas form is crucial for individuals receiving food assistance, as it helps determine ongoing eligibility. In addition to this form, several other documents may be required to support your application or report changes in your circumstances. Below is a list of related forms and documents that are often used in conjunction with the ES-3114.
These forms and documents work together to ensure that your application for food assistance is complete and accurate. Providing the necessary information helps maintain your eligibility and access to benefits, so it’s essential to stay organized and informed.