This worksheet is to be completed for all families who report no income or whose total tenant payment equals the minimum rent. The form must be completed prior to admission and every 90 days thereafter until the household begins recieving income. This form is to be completed and submitted will all required supporting documentation within 10 business days of our request for the information, or you will be considered non-compliant, and your housing assistance will be in jeopardy. Failure to complete and submit the required documenation as requested will result in denial or termination of assistance.
If you share a plan with someone outside the household, you must list the amount above and the person below.
If you share accounts/subscriptions with someone outside the house and they pay, you must list the amount and person.
Below are various miscellaneous expenses. Please select yes or no for each expense. If an expense applies to your family, please enter the MONTHLY amount, and how you pay for it.
I certify that there is no income coming into my household, other than noted on this worksheet and income statement. I understand that if I don't report income, and it is later found that my household had income, I could be required to repay the housing authority any monies that were overpaid by the housing authority for rent assistance.
I understand that failure to report income is a violation of the housing program and may be terminated from the rental assistance program for non-compliance/non-reporting income.
I understand that when my household starts receiving income, it must be reported to the housing authority within 10 business days.
I understand that any misrepresentation of information or failure to disclose information requested on this worksheet may disqualify me from consideration for admission or participation in any housing assistance program.
All documentation to support your expense and proof how how those expenses are paid must be submitted with this completed form. You know what expenses you have declared in this worksheet, and you are respoinsible for submitting all documentation to support the expense.
Below are file upload boxes for you to submit documentation. If you do not have your documentation right now, please submit the form and contact your housing worker for their email address, so you can email the documentation to them. If you prefer, the documentation may also be mailed to the housing authority at:
NW MN Multi-County HRAPO Box 128Mentor, MN 56736