10-DAY CHANGE FORM

Other Income received within the entire household by all family members

I need to report a change in my current job or add new job
Present / New Employer Name
Present / New Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Present / New Employer Phone Number

Area CodePhone Number
Present / New Employer Fax Number

Area CodePhone Number
Date of Hire

MonthDayYear
Date
Pay Rate
How often are you paid
Number of Hours worked per week
Income Verification Caseworker
Income Verification Your Name

First NameLast Name
Last four of Social Security Number for Income Verification
We are required to verify assets, income and certain expenses of all persons applying for admission to or living in Federally Assisted Housing. To comply with this requirement we ask for your cooperation in supplying the information requested regarding the referenced individual. This information will be used solely to determine eligibility or rent. I hereby authorize the release of this information.
Signature
Date

MonthDayYear
Date

FIXED INCOME VERIFICATION FORM
Fixed Income Change (Social Security, SSDI, etc)
Fixed Income Caseworker
I authorize the release of information to the Plano Housing Authority regarding any fixed income.
Fixed Income Verification Your Name

First NameLast Name
Social Security Number for Fixed Income Verification
Signature
Date

MonthDayYear
Date

ZERO INCOME

For All Adult Household Members
Zero Income for all family members
Caseworker for Zero Income Certification
Your Name for Zero Income

First NameLast Name
Address for Zero Income

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number for Zero Income

Area CodePhone Number
Email for Zero Income
example@example.com
I receive cash contributions or gifts including rent, groceries, car payments, or utility payments on an ongoing basis from person(s) not living with me.
If Yes, list the source #1 name
Source #1 Monthly Amount Provided
If yes, list Source #1 Address

Street Address

Street Address Line 2

CityState

Zip Code
If yes, list Source #1 Phone Number

Area CodePhone Number
If Yes, list the source #2 name
Source #2 Monthly Amount Provided
If yes, list Source #2 Address

Street Address

Street Address Line 2

CityState

Zip Code
If yes, list Source #2 Phone Number

Area CodePhone Number
Total Monthly Income and Cash provided to you from other sources besides the two already listed.
Checking Account Bank Name
Checking Account Bank Account Number
Checking Account Current Balance
Savings Account Bank Name
Savings Account Bank Account Number
Savings Account Current Balance

Zero Expense Sub Total #1
Zero Expense Sub Total #2
Zero Income Total Monthly Income and Cash Contributions
Zero Income Total Monthly Expenses Paid
Zero Expenses amount greater than income
If the Expenses are greater than the income explain how you are paying all of your monthly expenses.
Zero Expenses amount less than income
Section 1001 Warning

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentations to any department or agency of the United States as to any matter within its jurisdiction. If you or anyone in your family is a person with disabilities and require a specific accommodation in order to fully utilize our programs and services, please contact our Compliance Department at 972-423- 4928 x370.
Signature
Date

MonthDayYear
Date

Rows	Amount Spent Monthly
Family Share of Rent
Garage / Storage
Pet Food / Pet expenses
Food (amount in excess of Food Stamps)
Clothing
Utilities Gas
Utilities Electric
Utilities (Water and Sewer)
Medical / Dental
Credit Card
Car Payment
Car Insurance
Travel Expense (Gas for Car, Bus Fare, etc)
Home Phone
Cell Phones for all family members
Internet / Cable
Paper Products
Cleaning / Grooming
Satellite TV
Cigarettes / Tobacco
Entertainment

Click the SUBMIT button below to automatically SUBMIT the change form to your case worker. You will receive a copy back by e-mail.
Should be Empty: