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___________________________­­­­­­­­­­­­­­­___________