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                               TENANT CHANGE REPORT FORM

ALL CHANGES MUST BE REPORTED WITHIN TEN DAYS OF OCCURRENCE.

PLEASE REPORT ALL CHANGES PRIOR TO THE 25TH OF THE MONTH TO ALLOW PROPER TIME TO VERIFY INFORMATION.

USE THIS FORM FOR REPORTING ANY CHANGES.

NO CHANGES WILL BE ACCEPTED UNLESS REPORTED ON THIS FORM

(Supply the appropriate documents for the change(s))

Signatures below constitute consent for Aberdeen Housing Authority to contact any agencies, organizations, offices, or individuals necessary to verify any information needed for my/our participation in the housing assistance programs.

DATE: __________________________

_________________________________________             __________________________________________    

Head of Household Name                                        Signature

                                

_________________________________________                    __________________________________________

Address                                                        Phone

_________________________________________                   Are we able to text you?  Yes_______ No_______

Email Address                                                           (Standard messaging rates apply)

Please fill out the following section(s), which apply to the change(s) being reported.

A.        NEW INCOME:  ___PERMANENT  ___TEMPORARY  ___SEASONAL

 

        Name of family member with change: ____________________________________________________

        Type of income (ex: wage, child support, SS, SSI, etc)_______________________________________

        Amount receiving: _____________                How often received_______________________________

        Date when family member starting receiving new income ____________________________________

If the new income is from employment, complete the following:

Employer: ___________________________________________

Employer Address: ____________________________________

Employer Phone: ______________________________________        Employment starting date: ______________

PLEASE ENCLOSE A SIGNED, DATED STATEMENT FROM EMPLOYER TO VERIFY STARTING DATE AND WAGES.

  1. INCREASE, DECREASE OR LOSS OF INCOME:

Name of family member with change: ___________________________________________________

Type of income (ex: wage, child support, SS, SSI, etc) ______________________________________

        ____Increase        _____Decrease  ______No longer employed

New amount receiving: ___________How often received: _____________________________

Date when this increase/decrease/loss of income started:  ____________________________________

If this change is due to employment, complete the following:

Employer: _____________________________________________

Employer Address: _____________________________________Employer Phone:__________________

  1. CHANGE OF FAMILY MEMBERS:

If adding/removing household members, you must talk to your case worker when handing in the form.

Family members who have moved into or out of the household:

                

Legal Name                                                     Relation       Age      Sex       Birthdate       Birthplace

                                                                                                             

1._________________________SS#___________        ________     ____    _____   __________   ___________

2._________________________SS#___________        ________     ____    _____   __________   ___________

3._________________________SS#___________        ________     ____    _____   __________   ___________

Date Moved In:   ___________________                Date Moved Out:  ____________________        

  1. CHANGE OF CHILDCARE COSTS:

____ I have the following childcare costs:

Name of childcare provider: _________________________________________________________________

Address of childcare provider: _______________________________ Phone: __________________________

Amount of childcare cost: __________________________How often paid: ___________________________

Name of children childcare is provided for:  _____________________________________________________

Amount of childcare reimbursement, if any _____________________________________________________

____ I no longer pay childcare costs.  Date last paid for childcare ______________________________

  1. CHANGE IN MEDICAL EXPENSES:

I have the following changes in medical expenses: __________________________________________

I no longer have the following medical expenses: ___________________________________________

  1. NAME CHANGE:

Current Name                        Changing To                        Date of Change

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMMENT SECTION (For office use only):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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