Employment and Earnings Reporting Requirements

• The Division and Department of Human Services (DHS) will have access to your reported earnings. The form is submitted online.
• DHS uses the information in this form to calculate any income disregards. An Income Disregard allows DHS to exclude part of the income you earn from your job when determining your benefits. Without the income disregard, you may be required to pay a portion of your cost of care.
• The Division will forward referrals to The Sherlock Center for Benefits Planning. The Sherlock Center will contact you and/or your agency to arrange for the Benefits Plan.

Use this form to report 1) a new job, 2) any change in position, hours, or wages; or 3) when you leave a job.

All individuals receiving services through the Division are required to report income and employment. The Employment and Earnings Form should be completed if any of the following apply:

• You get a new job, a second job, change jobs, get a promotion, leave your job, or have another change in your employment;
• You have a change in income, such as getting a raise;
• You permanently get more hours at your current job (such as going from 10 hours per week to 15);
• You would like to receive benefits counseling