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Blank Oregon Snap Change Report Form

The Oregon SNAP Change Report form is a document used by participants in the Supplemental Nutrition Assistance Program (SNAP) to report changes in their circumstances that may affect their benefits. This program, formerly known as food stamps, assists low-income households in purchasing food to maintain proper nutrition. Understanding how to properly complete this form is essential for ensuring continued eligibility and maximizing benefits.

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The Oregon SNAP Change Report form plays a crucial role in the administration of the Supplemental Nutrition Assistance Program (SNAP), a federal initiative designed to assist low-income households in securing adequate nutrition. This program, which has evolved from the former Food Stamp Program, provides eligible participants with Electronic Benefits Transfer (EBT) cards—commonly referred to as Oregon Trail cards—allowing them to purchase food items at participating retailers. Eligibility for SNAP benefits is primarily determined by income and resource levels, with specific provisions for U.S. citizens and certain non-citizens. The Change Report form is essential for beneficiaries to communicate any significant changes in their circumstances that could affect their eligibility or benefit amounts. These changes may include fluctuations in income, household composition, or expenses related to housing and childcare. Understanding the financial tests involved, such as the resource and income tests, is vital for applicants to navigate the program effectively. Additionally, the form serves as a tool for recipients to ensure they receive the correct amount of benefits, as it allows for adjustments based on reported changes. By maintaining accurate and timely communication with the Department of Human Services (DHS), individuals can maximize their benefits and support their nutritional needs.

Form Example

ODHS 0853 (10/2025), Recycle prior versions
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Simplied Reporting System for Supplemental
Nutrition Assistance Program (SNAP)
Keep this for future use. It explains simplied reporting.
What is simplied reporting?
The Simplied Reporting System (SRS) is a way for some Supplemental Nutrition Assistance Program
(SNAP) recipients to report changes while they are receiving benets.
What to report?
Report by the 10th day of the month after the change when:
● The household’s total gross income for a month is more than the
limits to the right. (Gross income is the amount before deductions,
such as taxes.)
● When anyone in the household won $4,500 or more from
lottery or gambling.
What about other changes?
You do not need to report any other changes. But you may want to
report changes that will give you more benets.
Examples of changes that may increase benets include: if your
income goes down, your rent goes up, someone moves into your
home, you have out of pocket dependent care costs or medical
expenses for elderly or disabled individuals.
You can report these to the Oregon Department of Human Services (ODHS) in writing, by phone, online,
email or in person.
How to use this form
● Use this form to report changes for SNAP food benets.
● Attach proof of income changes.
● Complete only the parts that describe your changes.
● Sign and date the form.
If a change a󰀨ects your benets, the Oregon Department of Human Services (ODHS) will send you a notice.
We usually make changes the month after you report them.
Household size Amount
1 $1,696
2 $2,292
3 $2,888
4 $3,483
5 $4,079
6 $4,675
7 $5,271
8 $5,867
If more than 8, add $596
for each additional person.
ODHS 0853 (10/2025), Recycle prior versions
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Non-discrimination statement
The Oregon Department of Human Services (ODHS) does not discriminate against anyone. This
means that ODHS will help all who qualify and will not treat anyone di󰀨erently because of age, race,
color, national origin, gender, religion, political beliefs
1
, disability or sexual orientation.
You may le a complaint if you believe ODHS treated you di󰀨erently for any of these reasons.
To le a complaint with the state, you can call the Governor’s Advocacy O󰀩ce at 1-800-442-5238
(TTY 711) or write to their o󰀩ce at:
Governor’s Advocacy O󰀩ce
500 Summer Street NE, E17
Salem, OR 97301
Email: [email protected]
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, this institution is prohibited from discriminating based on race, color,
national origin, sex (including gender identity and sexual orientation), religious creed, disability, age,
political beliefs, or reprisal or retaliation for prior civil rights activity.
To le a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA
Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/
sites/default/les/documents/ad-3027.pdf, from any USDA o󰀩ce, by calling (833) 620-1071, or by
writing a letter addressed to USDA.
The letter must contain the complainant’s name, address, telephone number, and a written
description of the alleged discriminatory action in su󰀩cient detail to inform the Assistant Secretary
for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed
AD-3027 form or letter must be submitted to:
Mail:
Food and Nutrition Service, USDA
1320 Braddock Place, Room 334
Alexandria, VA 22314; or
Fax:
(833) 256-1665 or (202) 690-7442; or
Email:
[email protected]
Program information may be made available in languages other than English. Persons with
disabilities who require alternative means of communication to obtain program information (e.g.,
Braille, large print, audiotape, American Sign Language), should contact the agency (state or local)
where they applied for benets. Individuals who are deaf, hard of hearing or have speech disabilities
may contact USDA through the Federal Relay Service at (800) 877-8339.
Other formats and languages
You can get this form in other languages, large print, braille or a format you prefer free of charge.
Contact the ONE Customer Service Center at 1(800)699-9075 or 711 (TTY) or by email at Oregon.
Bene[email protected]. We accept all relay calls.
This institution is an equal opportunity provider.
1 SNAP participants are protected against political belief discrimination.
ODHS 0853 (10/2025), Recycle prior versions
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Penalties in the Supplemental Nutrition Assistance Program
You do the following... You will lose food benets...
● Hide information or make false statements;
● Use Electronic Benets Transfer (EBT) cards that
belong to someone else;
● Use food benets to buy alcohol or tobacco;
● Trade or sell benets or EBT cards;
● Dump containers only for the cash redemption value;
● Resell food bought with food benets for cash.
● 12 months for the rst o󰀨ense;
● 24 months for the second o󰀨ense;
● Permanently for the third o󰀨ense.
● Trading food benets for controlled substance
such as drugs.
● 24 months for the rst o󰀨ense;
● Permanently the second o󰀨ense.
● Trading food benets for rearms, ammunition
or explosives.
● Permanently.
● Trading, buying or selling food benets of $500
or more.
● Permanently.
● Giving false information about who you are or where
you live so you can get extra food benets.
● 10 years for each o󰀨ense.
You also can be ned up to $250,000, put in prison for up to 20 years or both.
You may go to court under other federal laws.
If you knowingly do the following... You may be...
● Use EBT cards which are not yours;
● Transfer your EBT cards to other people;
● Acquire or possess EBT cards which are not yours.
● Guilty of a felony or misdemeanor;
● Fined;
● Put in prison;
● Ineligible for food benets for a
period of time.
ODHS 0853 (10/2025), Recycle prior versions
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Turn in this page to report a change.
Simplied Change Report for Supplemental
Nutrition Assistance Program (SNAP)
Keep this form until you have a change to report. You can report changes
in writing, online, email, in person or by calling the ONE Customer Service
Center at 1-800-699-9075 or 711 (TTY). You may call collect, if needed.
What you must report by the 10th day of the month
after the change
● When your household’s gross monthly income (before
deductions, such as taxes) is more than the amount for
your household size in the table to the right.
● When anyone in the household won $4,500 or more from
lottery or gambling.
Household size Amount
1 $1,696
2 $2,292
3 $2,888
4 $3,483
5 $4,079
6 $4,675
7 $5,271
8 $5,867
If more than 8, add $596
for each additional person.
I want to report:
My total household gross income last month was more than the amount shown above.
The income totaled: $ (attach proof of income)
The income went up because:
The income is expected to be the same this month. Yes No
Someone in my household won $4,500 or more from lottery or gambling.
The winnings received by , totaled: $ .
I have moved to a new address:
Change in shelter cost: Change in utilities:
Something else. You can report changes that could increase benets. For example: your shelter costs
went up, someone moved into your home, you have out of pocket dependent care costs or medical
expenses for elderly or disabled individuals:
By signing this form, I a󰀩rm under penalty of perjury I have given true and complete information.
I realize that making false statements or hiding information may subject me to state and federal
penalties. I have read this form and understand it. This is legally binding.
Full legal signature of primary person Date
Case number:
Case name:
↓ Oregon Snap Change Report PDF Form

Document Characteristics

Fact Name Details
Program Overview The Supplemental Nutrition Assistance Program (SNAP) helps low-income households purchase food. It provides benefits through Electronic Benefits Transfer (EBT) cards, known as Oregon Trail cards.
Eligibility Criteria To qualify for SNAP benefits, applicants must be U.S. citizens with modest or low income. Non-citizens may also qualify under specific conditions.
Financial Requirements Applicants must meet two financial tests: a resource test (total resources must not exceed $2,000 or $3,250 for certain individuals) and an income test based on adjusted income limits.
Benefit Calculation SNAP benefits are determined by household size and income. Various deductions can increase the benefit amount, including dependent care and medical expenses.
Application Process To apply for SNAP, individuals must contact their local Department of Human Services (DHS) office. Applications can be expedited under certain conditions.
Reporting Changes Beneficiaries must report certain changes to DHS, such as income increases or changes in household expenses, to ensure accurate benefit amounts.
Denial of Benefits If an application is denied, individuals receive a notice explaining the reasons. They have 90 days to request a hearing to contest the decision.
Governing Laws OAR 461-165-0082, OAR 461-120-0125, OAR 461-160-0015, OAR 461-135-0505, OAR 461-115-0210, OAR 461-130-0315, OAR 461-025-0310.
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