Congregate care change form 2026

1. Click ‘Get Form’ to open the congregate care change form in the editor.
2. Begin by filling out the Client Identification section. Enter the client's name, last four digits of their Social Security Number, date of birth, new residence address, and mailing address if different.
3. In the Nature of Placement section, indicate the type of placement and care by selecting from options such as Congregate Care Level 1, Level 2, or Level 3. Specify whether it is a move into or out of a facility.
4. Complete the Custody section for children under 18 by identifying who has legal custody—options include Parent/Guardian or Social Services.
5. Document any Income Changes by specifying the type of income, amount, and date when this income changed.
6. Fill in Resources by stating total countable resources and their effective date.
7. For Direct Deposit Authorization, provide bank details including account name, routing number, and account type. Ensure signatures are included where required.
8. Finally, complete the Authorization section with your name, signature, title, date, telephone number, and email address.

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