The statement shall include: 1. If household change results in a change in income, please refer to Section 5 of this form for income change guidelines.Page 3. DOC.231.21C. Miscellaneous Forms. Effective Date Change Form (pdf). This Manual Release clarifies requirements regarding the impact of income changes on eligibility and the recipient's available income for the cost of care. Modifying Lease; Sample Lease Cancellation Agreement. Use this form to request to change your address on record with the court in the District Court where your case is scheduled or will be heard. Please complete the. The effective date of this change will be the date of your approval.