This form is to be used as a sample or guideline only

Line 3w – enter the Social Security Number (SSN) of the former (deceased) HOH. Other Household Changes. If, in scenario B or C above, there is also a change in family income and composition resulting in a change in the family’s total family share and/or unit size, the effective date on line 2b should be the effective date of the new total ... ................
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