Change Reporting Form

CHANGE REPORTING FORM

This form is to report any changes in income, expenses, or household composition
Northwest Minnesota Multi-County HRA Requires ALL household changes to be reported within 10 business days of the change. Please complete all changes that apply to your household using this form. If you do not provide full information in a timely manner, you may be required to repay any overpaid assistance, or it may delay a reduction in your rent portion.

Appropriate verifications MUST be submitted with this form. Verifications can be submitted at the end of this form, faxed to 218-637-2433, or emailed to your caseworker. Please contact your caseworker to request their email address.
Head of Household Full Name*
Last 4 of SSN*
Address*

Current Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone*
Cell Phone
What change do you have to report?*

Change of AddressIncome ChangesExpense ChangesFamily Composition Changes
Change of Address

for waiting list applicants only
Address*

New Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Date Moved to Address*

MonthDayYear
Date
What kind of income change did you have?*

EmploymentSocial Security/SSI/SSDI/RSDIMFIP/Welfare/County AssistanceChild SupportUnemploymentOther
Change in Employment

verification for each income change must be submitted (60 days of paystubs, verification of employment, verification of loss of employment, etc.)
What type of employment change?*

New employmentLoss of employmentChange in Wages/Hours
Have your wages increased or decreased*

IncreasedDecreasedWages have not changed
New Income Amount*
Frequency of income*

HourlyWeeklyBi-weeklyMonthly
Have your hours increased or decreased?*

IncreasedDecreasedHours have not changed
New Amount of Hours*
Frequency of Hours*

HourlyWeeklyBi-weeklyMonthly
Employer Name*
Phone Number*
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Start Date of Employment*

MonthDayYear
Date
End date of Employment*

MonthDayYear
Date
Loss of Employment - you MUST identify a source of replacement income by selecting one of the following*

UnemploymentMFIP/Welfare/County AssistanceLooking for WorkOther
Type of Other Income:
Change to Social Security/SSI/SSDI/RSDI
Social Security/SSI/SSDI/RSDI*

IncreasedDecreased
New Income Amount*
Frequency of Payments*

WeeklyBi-weeklyMonthly
Change to MFIP/Welfare/County Assistance
MFIP/Welfare/County Assistance*

IncreasedDecreased
New Income Amount*
Frequency of Payments*

WeeklyBi-weeklyMonthly
Change to Child Support
Child Support*

IncreasedDecreased
New Income Amount*
Frequency of Payments*

WeeklyBi-weeklyMonthly
Change to Unemployment
Unemployment*

IncreasedDecreased
New Amount*
Frequency of Payments*

WeeklyBi-weeklyMonthly
Change to Other income
Other Income Type*

IncreasedDecreased
New Income Amount*
Frequency of Payments*

WeeklyBi-weeklyMonthly
Source of Other Type of Income*
Expense Changes (COMPLETE ALL THAT APPLY)

Verification for each expense must be submitted
What expense changes did you have?*

Child Care ExpensesMedical Expenses
Child Care Expenses - Only for children 12 years old or younger while adult is employed or attending school

Statement from your childcare provider showing the number of hours per week/month and the weekly/monthly expense amount is required.

Reminder: if you are also receiving daycare assistance from the county, we do not count the amount the county pays as an expense. The expense MUST BE paid by you out-of-pocket.
Child Care expenses*

IncreasedDecreased
New Expense Amount*
Frequency of expenses*

WeeklyBi-weeklyMonthlyAnnually
Out of Pocket Medical Expenses - Only if age 62 or older, handicapped, or disabled

Types of Medical Expenses - Prescription Drugs, Past Due Medical Bills, Doctor/Clinic Bills, Dental Bills, Health Insurance Premiums, etc.

Verifications must be submitted. (monthly statement, bill, verification of medical expenses, 12-month printout from pharmacy, etc.)
Out of Pocket Medical Expenses*

IncreasedDecreased
New Expense Amount*
Frequency of Expenses*

MonthlyBi-AnnuallyAnnually
Expense Type*
Name/Location/Doctor Where Expense Is*
Do you have additional medical expenses*

YesNo
Out of Pocket Medical Expenses*

IncreasedDecreased
New Expense Amount*
Frequency of Expenses*

MonthlyBi-AnnuallyAnnually
Expense Type*
Name/Location/Doctor Where Expense Is*
Family Composition Changes
Which of the following are you requesting?*

Someone to move inSomeone to move out
Requesting the following person(s) to move in

Copy of Social Security Card is required for ALL household members. Copy of Driver's License/Photo ID is required for all adult household members (18+). Proof of income is required if the new household member has income. Copy of bank statements are required if the new member has any bank accounts/assets.
FULL Name (First, Middle, & Last)*
Social Security Number (submit copy of Social Security Card)*
Date of Birth (Submit copy of Birth Certificate. If over 18, copy of Driver's License)*

MonthDayYear
Date
Relationship to Head of Household*
Requested Move In Date*

MonthDayYear
Date
Does this person have an income?*

YesNo
If yes, Income Amount*
Frequency of Income*

HourlyWeeklyBi-weeklyMonthly
Source of Income (submit copies of income statements)*
Are you requesting an additional person to move in?*

YesNo
FULL Name (First, Middle, & Last)*
Social Security Number (submit copy of Social Security Card)*
Date of Birth (submit copy of Birth Certificate. If over 18, copy of Driver's License)*

MonthDayYear
Date
Relationship to Head of Household*
Requested Move In Date*

MonthDayYear
Date
Does this person have an income?*

YesNo
If yes, Income Amount*
Frequency of Income*

HourlyWeeklyBi-weeklyMonthly
Source of Income (submit copies of Income Statements)*
The following person(s) moved out
Name*
Date Moved Out*

MonthDayYear
Date
Address to where they moved to*

Street Address

Apt. #/Unit

CityState

Postal / Zip Code
Did they have an income?*

YesNo
If yes, Income Amount*
Frequency of Income*

HourlyWeeklyBi-weeklyMonthly
Source of Income*
Did an additional person move out?*

YesNo
Name*
Date Moved Out*

MonthDayYear
Date
Address to where they moved to*

Street Address

Apt#/ Unit

CityState

Postal / Zip Code
Did they have an income?*

YesNo
If yes, Income Amount*
Frequency of Income*

HourlyWeeklyBi-weeklyMonthly
Source of Income*

I/We certify that the information given is accurate and complete to the best of my/our knowledge and belief. I/We understand that providing false information is punishable under Federal and State Law and is grounds for termination of my/our housing assistance.

ALL ADULT HOUSEHOLD MEMBERS MUST SIGN THIS FORM.
Head of Household Signature*

Clear
Date*

MonthDayYear
Date
Is there another adult household member that needs to sign this form?

YesNo
Adult Member Signature*

Clear
Date*

MonthDayYear
Date
VERIFICATION UPLOAD

If you would like to submit your verifications with the form, please submit them below. If you do not submit them now, they MUST be faxed to 218-637-2433 or emailed to your case worker.
File Upload

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CHANGE REPORTING FORM

Change of Address

Change in Employment

Change to Social Security/SSI/SSDI/RSDI

Change to MFIP/Welfare/County Assistance

Change to Child Support

Change to Unemployment

Change to Other income

Expense Changes (COMPLETE ALL THAT APPLY)

Child Care Expenses - Only for children 12 years old or younger while adult is employed or attending school

Out of Pocket Medical Expenses - Only if age 62 or older, handicapped, or disabled

Family Composition Changes

Requesting the following person(s) to move in

The following person(s) moved out

VERIFICATION UPLOAD