CHANGE IN HOUSEHOLD INCOME/COMPOSITION

CHANGE IN HOUSEHOLD INCOME/COMPOSITION

Fully complete and sign all pages and the release of information form. Return all forms, including supporting documentation, to LDCHA. No change in rent can be made until this form is submitted and the information reported verified by LDCHA staff. Please contact staff should you have any questions on required documentation.
PLEASE GIVE A BRIEF DESCRIPTION OF THE CHANGE BEING SUBMITTED*
Full Name of Person Completing This Form*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Full Name of Head of Household*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
HOUSEHOLD COMPOSITION (IF CHANGED)

List all members of the assisted household.
Is there a parent of a child listed that is not in the household?

YesNo

SOURCES OF INCOME (GAINED OR LOST)

Earned Income: If changed, list all sources of income for all household members including children. Provide the three most recent pay stubs from any changed employer.
Employer 1:
Household Member Employed
Employer’s Name
Employer’s Phone #
Address of Employer

Street Address

Street Address Line 2

CityState

Zip Code
Employer 2:
Household Member Employed
Employer’s Name
Employer’s Phone #
Address of Employer

Street Address

Street Address Line 2

CityState

Zip Code
OTHER SOURCES OF INCOME (IF CHANGED)

I do hereby certify that I have income from the following sources:

SOURCE/TYPE OF INCOME

	Family Member	Income Source i.e. SSI or SSDI	Monthly Amount
Unemployment Benefits
Worker’s Compensation
Child Support/Alimony
TANF/General Assistance
Food Stamps
Social Security/ SSI/SSDI
Pension/Annuity/VA Benefits
Cash Contributions
Interest/Dividend Income
Tribal Allotments/Payments
Student Financial Aid

FINANCIAL ASSETS (IF CHANGED)

This section only applies to adults in the household. Please provide the most three recent consecutive statements. Describe and give the current value to all assets.
Checking Account
Name of Bank
Balance
Amount
Checking Account
Name of Bank
Balance
Amount
Savings Account
Name of Bank
Balance
Amount
Savings Account
Name of Bank
Balance
Amount
Stocks/Bonds/Trust
Name, Number & Maturity Date
Value
Amount
Stocks/Bonds/Trust
Name, Number & Maturity Date
Value
Amount
Other Assets
Describe
Value
Amount
Please attach any supporting documentation you have in relation to job loss, unemployment income or new income.

If you are unable to attach the documents to this form, please email to: occupancy@ldcha.org
Supporting Document 1

Browse Files

Cancelof
Supporting Document 2

Browse Files

Cancelof
Supporting Document 3

Browse Files

Cancelof
Supporting Document 4

Browse Files

Cancelof
ZERO INCOME (IF NEW)

If no income is reported, please sign below to certify that you receive ABSOLUTELY ZERO income:
Signature

Clear
Warning: Section 1001 of title 18 of the United States codes makes it a criminal offense to make willful, false statements or misrepresentation to any department or agency of the United States as to any matter within its jurisdiction. Under Federal Regulations the Lawrence-Douglas County Housing Authority is charged with determination and verification of complete household income for all persons receiving or applying for housing assistance. Failure to supply requested income information that is true, accurate and complete is grounds for denial and/or termination of housing assistance and may lead to a debt for overpayment of housing assistance and to prosecution for criminal fraud against the housing authority.
TENANT CERTIFICATION

I/We certify that all information given to the Lawrence-Douglas Housing Authority on household composition, income, net family assets, allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. I/We understand that false statements or information are grounds for termination of housing assistance and termination of tenancy. Under penalty of perjury I/we do hereby certify to the information provided in this Change in Household Income/Composition.
Signature of Head of Household:

Clear
Date

MonthDayYear
Date
Signature of Other Adult

Clear
Date

MonthDayYear
Date
Signature of Other Adult

Clear
Date

MonthDayYear
Date
NOTE TO TENANT: If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll Free Hot Line at (800) 424-8590.
Should be Empty:

CHANGE IN HOUSEHOLD INCOME/COMPOSITION

HOUSEHOLD COMPOSITION (IF CHANGED)

SOURCES OF INCOME (GAINED OR LOST)

OTHER SOURCES OF INCOME (IF CHANGED)

FINANCIAL ASSETS (IF CHANGED)

Please attach any supporting documentation you have in relation to job loss, unemployment income or new income.

ZERO INCOME (IF NEW)

TENANT CERTIFICATION