**Keep in mind that you do not need to mail this print-out to your local agency.

** TRACEY L CROSBY , thank you for using COMPASS to report your changes, your online Change Report was submitted on June 1, 2011 at 12:23 P.M. Your tracking number is 5010679558. Next Steps Please keep in mind that it can take up to 10 days for your worker to process your changes. In most cases, your change will be processed within 10 days. Please keep in mind that in some cases, the change you've told us about may not result in any change in benefits. Unless you have another change, you shouldn't call your worker to tell them about the change you've just reported through COMPASS. As a next step, your worker may ask you to provide proof of some of the changes you've told us about. If your worker asks for proof, you'll need to mail, fax or bring it in within 10 days of when your worker asked for it. If you report a change but don't give the proof your worker asks for, your benefits may end. If you can't find something, your worker may be able to help you get the proof you need. Here are some examples of what your worker may ask for: Proof of a Job Dated paycheck stubs for the last 30 days, or a statement from your employer. Proof of Other Income An award letter or a current benefit check. Proof of Housing and Utility Costs Mortgage or rent receipts, a lease or statement from your landlord, a property tax statement, or a cancelled payment check. Proof of Immigration Status Green Card or registration card. Proof of Citizenship Birth Certificate, Passport, Certificate of Naturalization, or Certificate of Citizenship. Proof of Social Security Number Copy of your Social Security Card or proof of application. Proof of Dependent Care Payment Cancelled check, receipt, or statement from provider. Proof of Pregnancy A signed and dated note from a doctor or other health care professional. This note needs to say that the person who is applying is pregnant. It should also state her due date. COMPASS Report My Changes Page 1 www.compass.ga.gov

Proof of Health Insurance Copy of insurance card. Proof of Immunization Certificate of immunization issued by any health care facility that includes the provider's signature and provides the next immunization due date, DHS Form 3231, or Child Care Immunization Certificate. Proof of Resources Bank statements, property deeds, vehicle registration, copy of life insurance policies, burial contracts.

Change Report Summary

Household Information Changes

New People In Your Home Who Jameesha Y Crosby Age: 19 Date of Birth 01/20/1992 Race Gender Female Marital Status Never Married SSN 253-83-6900 Previously Received Benefits? Yes Other Refugee type Does this person have a sponsor? What country is this Alien Registration person from? or I-94 Number Where does he/she Nursing facility or live? Nursing home? In This Home Military Service Veteran Status Number Hispanic No SSN Application Date

Black Known by any other Alternative Name name? No Citizen Status Type of refugee US Citizen Legal Status Qualified Date Resident of GA?

Date enter in to US to live

Migrant Farm Worker? Yes No Is this person a veteran or a spouse of a veteran? No

Relationship Information

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Who Jameesha Y Crosby Age: 19

Relationships is the daughter of TRACEY L CROSBY is the sister of JAMEESHA Y CROSBY is the sister of JEDARIUS M JONES is the sister of GERARD D REYNOLDS

Do they buy food and eat meals together? Yes Yes Yes Yes

School Enrollment Information Person Jameesha Age: 19 Graduation Status Earned high school equivalency or general equivalency diploma (GED) Type Of School Caring for a child under 6 years old? No Caring for a child 6 to 12 years old and daycare not available? No Enrollment Status Not in school School Name Caring for a child 6 to 12 years old and enrolled in daycare? No Date of Graduation None of the above In a federal or state funded work-study program? No

No

Room/Meals Information Who Jameesha Y Crosby Age: 19 Getting income from providing room and/or meals? No

Other Bills Information Who Jameesha Y Crosby Age: 19 Medical Bills? Doctor Hospital Bills Pays Room or Board No

Other Benefits Who Jameesha Y Crosby Age:19 Is Getting SSI No Receiving CSSP No Is /Was hospitalized for more than 30 consecutive days No Was in foster care when turned 18 No

Additional Information Who Blind or Disabled Convicted of Sanctioned a Drug by FSET Felony Page 3 Disqualified from Food Stamps Avoiding Violating Prosecution Probation Parole www.compass.ga.gov

COMPASS Report My Changes

Jameesha Y Crosby Age: 19

No

No

No

No

No

No

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