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Change Report

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                                                              INCREASE __________

 

DECREASE __________                                               

INCOME CHANGE REPORT

 

HEAD OF HOUSEHOLD_________________________________________   PHONE NUMBER ___________________________

 

SOCIAL SECURITY NUMBER____________________________________   PROGRAM _________________________________

All Rental Assistance participants have the responsibility of reporting in WRITING any change in income and/or family composition to the Seminole County Housing Authority office within 10 business days of the change. 

 

CHANGE OF INCOME:  You must report any change in your present income.  If reporting a decrease in income, it must be received by the 15th of the month in order for the new rent to be adjusted for the following month.  Adjustment will be made once the verification has been received by our office.

 

CHANGE IN EMPLOYMENT:

NEW JOB/PAY INCREASE:

Name of person with change: ____________________________________________________

 

NAME OF EMPLOYER____________________________________________PHONE NUMBER___________________________________

 

ADDRESS OF EMPLOYER ___________________________________________FAX NUMBER___________________________________

 

DATE OF HIRE____________________________ HOURLY RATE OF PAY_________________# OF HOURS WORKED______________

 

HOW ARE YOU PAID:  WEEKLY___________ BI-WEEKLY____________SEMI-MONTHLY____________ MONTHLY______________

 

FIRST PAYCHECK DATE ____________________                                          IS THIS A SECOND JOB?  YES__________ NO___________

 

DO YOU HAVE ANY CHILD CARE EXPENSES? YES______________   NO _____________      (IF YES, VERIFICATION REQUIRED)

 

TERMINATION OF JOB:

Name of person with change: ____________________________________________________

 

FORMER EMPLOYER  ___________________________________________ PHONE NUMBER _______________________________

 

ADDRESS OF EMPLOYER _______________________________________FAX  NUMBER___________________________________

 

LAST DAY WORKED_______________________  DATE OF LAST PAYCHECK_____________________________

 

List any other income in your household at this time or expect to receive within the next 60 days (i.e. Unemployment, Child Support)

 

_________________________________________________________________________________________________________

 

CHANGE IN BENEFITS RECEIVED:

 

SOURCE

HOUSEHOLD MEMBER

 

EFFECTIVE DATE

OLD AMOUNT

NEW AMOUNT

SOCIAL SECURITY

 

 

 

 

SSI

 

 

 

 

CHILD SUPPORT

 

 

 

 

UNEMPLOYMENT

 

 

 

 

TANF/AFDC

 

 

 

 

RELATIVE

 

 

 

 

OTHER

 

 

 

 

 

**APPLICANT/TENANT CERTIFICATION AND HUD FORM 9886(AUTHORIZATION FOR RELEASE OF INFORMATION) MUST BE SIGNED WITH ALL REPORTED CHANGES.

 

I understand that there are penalties if I knowingly omit information, or give false information.  I certify that my answers on this form are correct and complete to the best of my knowledge. 

 

Signature __________________________________________________________________ Date___________________________­­­­­­­­­­­­­­­___________

 

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