HOUSING CHOICE VOUCHER PROGRAM

STATUS CHANGE FORM

To be completed by current program participants only.

You must report in writing within ten (10) business day any change in your circumstance. This includes changes in employment income, pensions, benefits, assets, the number of persons living in your unit. and expenses such as new or no longer paying daycare. Failure to report these change is a violation of your family obligations and will lead to program termination. Complete the form (please print neatly) Do not leave any questions blank. If a question does not apply write n/a.

Please continue to pay your current tenant rent portion until you receive written notice from NRHA advising you of a change in your portion of rent.

Any individual with a disability or other medical need who needs an accommodation with respect to completing this form should contact their caseworker. This form must be fully completed and signed to be processed.

Head of Household (Please Print Neatly)

Last Name / First Name / Social Security Number
Street Address and Apt. # / Home Phone Number / Cell Number
City / State & Zip / Email Address

What change are you reporting?

  • Income Circle one Increase Decrease
  • Household Composition
  • Expense
  • Other

Income (Please attach pay stub (s), award letter (s) or other verification of any new income, loss of income or change.)

Previous Income Source (income to be removed)

Household Member / Name and Complete Mailing Address of Income Source and Telephone Number / Date Change Effective

New Income Source

Household Member / Name and Complete Mailing Address of Income Source and Telephone Number / Date Change Effective

HAS THIS CHANGE RESULTED IN YOU HAVING ZERO INCOME? Circle one Yes No

If yes, please complete Zero Income Certification Form.

Household Composition: I desire to add the following person (s)

Legal Name (As on SS Card) / Relation to Head / Social Security # / Date of Birth / Has Income
Yes or No

o  Landlord approval letter for person to move into unit

o  Consent to obtain criminal background records form

o  Income information of new family member

o  Court issued custody documents or notarized affidavit grant custody.

o  Social Security Card, Birth Certificate, Current Picture Identification and 214 Declaration

o  Authorization for Release for Information/Privacy Act Notice HUD 9886 for any persons 18 years and older

I desire to remove the following person (s) A statement is required to verify that household member will no longer contribute income to the household. (if applicable)

Name / Relation to Head / Social Security # / Age

New Expense (Child Care, Medical, Etc.)

Household Member / Expense / Name and Complete Mailing Agency and Telephone Number

The information above is true to be best of my knowledge and I am aware that any false statements will be grounds for program termination.

WARNING Title 18, Section 1001 of the United States Code states that a person is GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS to any department or agency of the United States

______

Signature of Head of Household Date

______

Signature of Spouse or Co-head Date

****If you have anyone outside your household helping you to complete this form, please provide their name and their relation to your family****

______

Name Relationship to Family Date

You may submit your form in person, via the mail, or e-mail (no faxes)

Mailing address: NRHA ATTN: HCV Dept. P. O. Box 968 Norfolk, VA 23501

Caseworker’s e-mails:

Annette Fagan = Kisha Saunders =

Cheryl Wiggins = Janene Taylor-Smith =

Valerie Garris = Sheila Melton =

Carla Delgado = Nastalgia Carter =

Deborah Jenkins = Tara Hyman =

Interim Recertification Form 07/2015