Raleigh Housing Authority - Change of Status
Interim Report
HOH Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Reported
*
-
Month
-
Day
Year
Date
Email
example@example.com
ANSWER AND PROVIDE PROOF OF THE CHANGE BEING REPORTED
Add or Remove a Household Member #1
Please Select
Add
Remove
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Add or Remove a Household Member #2
Please Select
Add
Remove
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
List any changes in household income sources and effective date of change:
Name of Employer
Address of Employer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone / Fax Number of Employer
Please enter a valid phone number.
If employment ended, list last day of work:
-
Month
-
Day
Year
Date
Date of new employment start:
-
Month
-
Day
Year
Date
Hours worked weekly
Amount paid per hour
How often are you paid
Once per week
Twice per week
Once per month
LIST ALL WAGES, SSA/SSI, ALIMONY, REGULAR SUPPORT OR CHILD SUPPORT RECEIVED
Amount of support payment
Frequency of support payment
Once per week
Twice per week
Once per month
Support payment paid to:
First Name
Last Name
Is this support court ordered?
Yes
No
Pending Court Order
List the date you will provide RHA with a print-out listing support payments received in the past 12 months.
-
Month
-
Day
Year
Date
LIST TOTAL MONTHLY COSTS FOR THE FOLLOWING ALLOWANCES
Childcare costs you paid for those 12 and younger:
List all Full-time students and where:
Non reimbursed out-of-pocket Medical costs paid for elderly/disabled:
Other:
COMMUNITY SERVICE REQUIREMENT
Are any non-elderly or disabled household members age 18 or older not working/or attending classes?
Yes
No
If yes, please list who:
*My signature below certifies that the information I have given to Raleigh Housing Authority on household composition and/or income is accurate and complete to the best of my knowledge. I understand that any false statements or information given are punishable under Federal Law and grounds for termination of the Lease.
Resident Signature
*
Phone Number
*
Please enter a valid phone number.
RHA Representative
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