INCOME CHANGE REPORTING FORM. Note: Your assistance may be terminated if you do not complete and return this form within 10 business days from

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Patrick Quinn
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INCOME CHANGE REPORTING FORM Add New Income Loss of Income Note: Your assistance may be terminated if you do not complete and return this form within 10 business days from the receipt or loss of

1 INCOME CHANGE REPORTING FORM Add New Income Loss of Income Note: Your assistance may be terminated if you do not complete and return this form within 10 business days from the receipt or loss of income. Housing Specialist Head of Household PHA SUBSIDY Name: $ TENANT PORTION $ Address: PRO-RATE BEGINNING DATE: Home Phone: Work Phone: PHA$ TENANT $ Cell Phone: Message Phone: NOTE: Please report ALL household income changes for ALL family members. IF YOU HAVE CHECK STUBS, TERMINATION NOTICE OR OTHER BACK-UP DOCUMENTATION PLEASE PROVIDE COPIES WITH THIS FORM. SOURCE OF INCOME Child Support One) HOUSEHOLD INCOME PERSON DATE INCOME RECEIVING BEGAN OR INCREASED FSR# DATE INCOME ENDED OR DECREASED Employment One) in Reported Earnings Complete attached employment verification form TANF One) Social Security/SSI One) Unemployment One) Provide unemployment benefit letter or self declaration letter Other (List) Is this change expected to be: permanent or temporary? GROSS AMOUNT RECEIVED MONTHLY Explain: WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED UNDER THIS TITLE OR IMPRISONED FOR UP TO 5 YEARS. Head of Household : Staff : Staff Member Received: 01/2010

2 INCOME DECLARATION FORM HEAD OF HOUSEHOLD: NAME: SSN Please provide information for ALL income received by ALL household members in the last 12 months. Employment: Family member employed Monthly Income $ Employer name Started Ended Employer address Employer phone Employer City State Zip Employer fax Family member employed Monthly Income $ Employer name Started Ended Employer address Employer phone Employer City State Zip Employer fax Must Circle Yes or No Amount Person Receiving Per Month OR Week Alimony Yes or No AND (Aid to Needy/Disabled) Yes or No Cash contributions from Yes or No family, friends or others Child Support Yes or No FSR account number(s) Yes or No List FSR account numbers 1) Child 2) Child OAP (Old Age Pension) Yes or No Pension and Retirement Yes or No Self Employment Yes or No SS (Social Security) Yes or No SSI (Supplemental Security Income) Yes or No Student Financial Aid Yes or No TANF (Temp Aid to Needy Families) Yes or No Unemployment Benefits Yes or No Veterans Benefits Yes or No Work Study Employment Yes or No Workers Compensation Yes or No Home Care Allowance Yes or No Other Yes or No WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED UNDER THIS TITLE OR IMPRISONED FOR UP TO 5 YEARS. This declaration form to be signed by all household members over the age of 18. : : : : Revised 4/2013

3 EMPLOYMENT VERIFICATION Applicant/Tenant SSN: The above-named person has applied for housing assistance. We are required to verify all information that is used in determining this person s eligibility or level of benefits. We ask your cooperation in providing the following information and returning it to the Housing Authority. Your prompt return of this information will assure timely processing. Please fax back this form or return in the enclosed self-addressed envelope. This applicant has consented to the release of information as shown below. By my signature, I consent to the release of information requested Employer Name EIN# Employer Address: Employer Phone # Employer Fax # Applicant/Tenant DO NOT complete the information below! The PHA will contact the employer to complete. EMPLOYER: PLEASE COMPLETE THE BOX BELOW THAT APPLIES TO THIS EMPLOYEE: Continuing Employee or New Hire Hire Base Pay Rate $ Per Hour $ Per Week $ Per Month (Choose one) Job Title Average Hours per Week at Base Pay How many weeks is employee paid per year? Overtime Pay Rate per Hour $ Average number of overtime hours expected in the next 12 months: Total Gross earnings for the past 3 months (if applicable) $ Is this job temporary? Yes No If yes, how long? Other compensation not included above (Specify for commissions, bonuses, tips etc ) For $ per (hour, week, month, year) Please circle one Employee Layoff/Termination s of employment to and gross earnings $ of termination: of final paycheck: Amount of final Paycheck: Do you anticipate rehiring this employee? If yes, when? Signed: : Print Name: Print Title: Telephone #: Fax #: PHA Use Only Form mailed or faxed (circle one) on No response to mail or fax Called to confirm information on Contact Person Time of call: Phone number called: Used another form of verification: Type: APV4 01/2010

4 Client s Name: Address: REQUEST FOR CHILD CARE ASSISTANCE INFORMATION Housing Manager Phone #: Child Care Provider Name: Address: Phone #: Fax #: Tax I.D. # (if applicable): Zip Code: By my signature, I consent to the release of information requested and certify the child care expenses are not paid by or reimbursed to me from any other source: ***** Clients! DO NOT complete the information below. The PHA will contact the childcare provider to complete ***** The above referenced client pays $ per month/week (please circle one) for child care. (If the family is receiving CCAP use parental fee portion only.) Child care is provided for: Child s Name: Child s Name: By my signature I certify to the best of my knowledge, the child care expenses are not paid by or reimbursed to the family from any other source. WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED UNDER THIS TITLE OR IMPRISONED FOR UP TO 5 YEARS. Signed : Print Name : Print Title : d : PHA USE ONLY EV form mailed or faxed (circle) on No Response on mail or fax Called to confirm employment on Contact Name

1 AUTHORIZATION FOR RELEASE OF INFORAMTION AND BACKGROUND INVESTIGATION The Colorado Springs Housing Authority, or any of its subsidiaries, may obtain information about you or any household applicant

5 1 AUTHORIZATION FOR RELEASE OF INFORAMTION AND BACKGROUND INVESTIGATION The Colorado Springs Housing Authority, or any of its subsidiaries, may obtain information about you or any household applicant 18 years of age or older, from a consumer reporting agency for placement purposes. Thus, you and any household applicant may be the subject of a consumer report and/or an investigative consumer report which may include information about character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as neighbors, friends, or associates. These reports may contain information relating to credit history, criminal history (State and Federal records), social security verification, address trace, motor vehicle records ( driving records ), verification of education and employment history, or other background checks as deemed appropriate by information produced from the check. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised Colorado Springs Housing Authority will be conducting Background Investigations and may collaborate with other outside organization(s). The scope of this notice and authorization is all encompassing; however, allowing the Company to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of housing assistance, to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. I/WE understand that, depending on program policies and requirements, previous or current information regarding my household or myself may be needed. Verification and inquires that may be requested include, but are not limited to: Family Composition Landlord History Identity and Marital Status Residence and Rental Histories Credit History Criminal Activity Employment Income and Assets Medical and Childcare Allowance(s) Drug Activity Alimony Banks or Other Financial Institutions Child Care Expenses Child Support Utility Companies VA Benefits Military Pay TANF, AND, OAP Courts Disability Assistance Pensions Schools and Colleges Tribal Benefits Annuities Medical Expenses Unemployment Benefits Law Enforcement Agencies I/WE understand and agree that HUD and/or the Colorado Springs Housing Authority may conduct computer matching programs in order to determine my eligibility, participation, continued participation, and/or level of assistance provided in or by the Section 8 Housing Choice Voucher Program, Section 8 Project Based Program, Public Housing, and/or Reduced Rent Program. If a computer match is done, I understand that I have the right to notification of any adverse information located therein or action taken as a result of such information so that I may disprove information that I believe to be incorrect. HUD and/or this Agency may in the course of its duties exchange such information with other Federal, State, and/or Local Agencies including, but not limited to, all entities and agencies listed in the previous section of this Release. ACKNOWLEDGEMENT AND AUTHORIZATION I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Company at any time after receipt of this authorization and throughout my residency, if applicable. I hereby authorize, without reservation, any law enforcement agency, any administrator, any state or federal agency, institution, school or university (public or private), information service bureau, credit reporting agency, utility company(s), previous and current employer(s), medical and childcare providers, previous and current landlords, veterans administration, welfare agencies, social services, social security administration, credit providers and bureaus, family support registry, and/or any entity which provides information relevant to personal history and activity, to provide any and all background information requested Colorado Springs Housing Authority, or another outside organization acting on

6 behalf of the Company, and/or the Company itself. I agree that a facsimile ( fax ), electronic, or photographic copy of this Authorization shall be as valid as the original. I/WE agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with this Agency and will remain valid and in effect for the duration of program participation. I understand that I have a right to review my file and correct any information that I can prove is incorrect. Head of Household: Household Applicant 18 years of age or over: Household Applicant 18 years of age or over: Household Applicant 18 years of age or over: Warning! Title 18, Section 101 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of agency of the United States. 2

NOTE: THIS FORM IS NOT A FAXABLE FORM, ORIGINAL APPLICATION IS REQUIRED.

NOTE: THIS FORM IS NOT A FAXABLE FORM, ORIGINAL APPLICATION IS REQUIRED. DUNN COUNTY HOUSING AUTHORITY 1421 Stout Road, Menomonie, WI 54751 PLEASE PRINT Phone 715-235-4511 ext. 204 Fax 715-235-9241 OFFICE USE ONLY Application Received on: Date Time AM/PM PHA Representative: