Passaic County Board of Social Services


    Use this form to report changes in circumstances for you and your family.

    Please provide the following information on the form:

    1. Name

    2. Case Number

    3. Contact information

    Basic Info

    Change of Address

    For address change please provide:

    1. Lease / Rent Receipt or a letter from your landlord, must include
      address.

    2. Mortgage statement.

    3. Letter from the person you are staying with and proof of their address.

    4. If it’s a new apt. we need a utility bill, ex. a current PSEG Bill.

    5. If you have a new home, we also need water and sewer bills if not
      included in the mortgage.

    Change in Employment

    For change in employment please provide:

    1. Weekly last four pay stubs, biweekly last two pay stubs

    2. If terminated proof of termination, if new hire then employment letter
      stating how much they will earn and hours per week.

    3. If self-employed, self-attestation is needed along with profit loss
      statement, and last income tax.

    4. If self-employed profit loss statement, last income tax or
      self-attestation.

    5. Contribution statement if someone is helping you cover expenses.

    Change in Income

    Income

    Name

    Amount

    Earnings

    Unemployment Child Support

    Social Security

    SSI/RSDI

    Pension

    Other sources of income

    For change in income (earned/unearned) please provide:

    1. Unemployment letter if new employment is out of state.

    2. Child Support

    3. Social Security or SSI/RSDI

    4. Pension, VA, or Employer

    Change in Household Composition

    Name

    DOB

    SSN

    Income Y/N

    Amount

    For a change in household composition please provide:

    1. If spouse or partner or other adults, we need proof of identity

    2. Proof of legal status, SS, and proof of income.

    3. If trying to remove a partner from the case: if divorced proof of
      divorce, if incarcerated or deported proof of proceedings

    4. If they moved, proof of address where they live and proof of voluntary
      or court ordered child support.

    5. If adding a newborn, proof of birth crib card and copy of social
      security card application, or birth certificate and ssn card or
      attestation of birth, proof of csp received.

    6. If an unrelated child we need proof of custody, ssn and birth
      certificate.

    7. Removing adult child- if under 22 we need proof of new address over 22
      we just need a statement.