Income review - tenant declaration form

Household members – Income details
Please attach support documentation for the following:
- Enter the Centrelink details for yourself and all household members aged 18 years and over. Proof of income is required for the previous 26 weeks for all wage/salary earners.
- Clear copies of pay slips only to be submitted.
Number of houshold members*

Household members - Income details

Rows	Full Name	Date of Birth	Relationship to you	Centrelink Reference Number (CRN)	Wages	Other Income
1
2
3
4
5
6

Change in household circumstances
To help us calculate your rent correctly, we require you to tell us if there have been any changes to your household circumstances.

E.g. any change in number or income of household occupants. Complete the section below. If you need to list more than two changes, please email separately to our Income Review team.

Has any of the following occured:
- any people that have moved in or out
- anyone in your house who has turned 18
- anyone has started / finished work
- Anyone whose benefits have changed
Please put details below. Complete the section below. Please list of all changes, alternativey email separately to our Income Review team at rentreviews@pacificlink.org.au
Date of Change (e.g. date that you started or stopped working, household member left or joined)*

DayMonthYear
Please describe your finacial change here*
Date of Change (e.g. date that you started or stopped working, household member left or joined)

DayMonthYear

Rows	Name of person	Details	Business ABN	Weekly Gross income
1

Rows	Name of person	Details of Property	Managing Agent	Weekly Gross income
1

Tenant declaration
I have understood the instructions given on this form. I understand that in order to have my rent subsidised, I must provide current income details for all household members.To the best of my knowledge, the information I am providing is a complete and accurate statement of the people living in my household and the income they and I receive. I understand that if any information is withheld or misleading, my rental subsidy could be cancelled and/or backdated and my tenancy could be at risk. Further, I give permission for Pacific Link Housing to confirm any of the above details with any of the parties detailed above. Proof of Identity*

Proof of Identity is mandatory for Pacific Link Housing to process this web form. Please upload one form of photo ID (e.g. driver’s license, ID card, passport), or two forms of non-photo ID (e.g. Medicare card, Centrelink card, bank card).
Cancelof
Signature
Date

DayMonthYear
Date
Should be Empty:

Household members – Income details