Today's Date

Participant Name

First

Last

CIF Number

Please complete this form to change your Physical and / or Mailing Address

Prior Address

Prior Physical Address

Address Line 1

City

State

Zip Code

Was Your Mailing Address the Same as Your Physical Address?

Yes
No

as list Your

Prior Mailing Address

Address Line 1

City

State

Zip Code

New Address

New Physical Address

Address Line 1

City

State

Zip Code

Date Change Took Place

Is Your New Mailing Address the Same as Your Physical Address?

Yes
No

New Mailing Address

Address Line 1

City

State

Zip Code

Date Change Took Place

Please list all members residing in current household

Name

Relationship

Program participants must attach documented proof of change in address by submitting all of the following: new lease or rental agreement, utility bill, SSTT – verification of residency form, Post office mailing address change, and/or any other form of proof that states new address.

True & Accurate Agreement

I attest that the information stated above is true and accurate. I understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination from the SSTT program and/or incur penalties as specified by program policies.

Participant Name

First

Last

Participant Signature

Clear Signature

TANF Change of Address

Please complete this form to change your Physical and / or Mailing Address

Prior Address

New Address

Please list all members residing in current household

Shingle Springs
Band of Miwok Indians

Mailing Address

Physical Address

Community Links