EmailMe Form - HCV: Interim Re-Examination

Head of Household must sign this form certifying accuracy of information provided.

WARNING:

Name of Head of Household *

First Last

Email

Mobile Phone

### - ### - ####

Home Phone

### - ### - ####

Work Phone

### - ### - ####

Message Phone

### - ### - ####

Which changes are you reporting? *

Working Income: Complete this section only if you are adding or removing earned income. If adding income, you must provide 3 current pay stubs OR a written statement from your new employer. If removing income, you must provide proof from that empolyer.

	Add/Remove?	Name of Person Working	Gross Payment	Frequency	Name of Employer
Income 1
Income 2
Income 3
Income 4

Income Contributions: Complete this section only if you are adding or removing income contributions. (If anyone living outside of your household gives you cash payments for expenses or pays your bills directly). If adding or removing, you must provide a written statement from the contributor.

	Add/Remove?	Name of Person Receiving	Gross Payment	Frequency	Name of Employer
Contributions 1
Contributions 2
Contributions 3
Contributions 4

Supplemental Benefits: Complete this section only if you are adding or removing benefits. If adding or removing, you must provide a current award letter or pay history for each benefit.

	Add/Remove?	Name of Person Receiving	Amount Received	Frequency
TANF
Social Security
SSI
Pension/Retirement
Veterans Benefits
Unemployment
Alimony/Child Support
Food Stamps
Other

Household Composition: Complete this section only if you are adding or removing persons from the household. For adding household members, you must provide a copy of the birth certificate and social security card for each member. If removing, proof of where this person is now living.

	Full Legal Name	Relation	Date of Birth	Gender	Disabled	Race	Ethnicity (Hispanic/Not Hispanic)
Add
Add
Add
Remove
Remove
Remove

Childcare: Complete this section only if you are adding or removing child care information. You must provide a current statement from the provider.

	Add/Remove?	Amount Paid	Frequency	Name of Provider	Address of Provider
Expense 1
Expense 2

Medical Expenses: Complete only if the Head of Household, Spouse, or Co-head is 62 years of age or older OR disabled. You must provide a history from the provider.

	Add/Removing?	Name of Person Claiming	Amount Claimed	Name of Provider	Address of Provider
Expense 1
Expense 2
Expense 3
Expense 4

Assets: Complete this section only if you are adding or removing assets. For adding an asset, you must provide a current bank statement. If removing, proof that the asset is longer/disolved.

Disability Assistance Expense: Complete this section only if you are adding or removing a Disability Assistance Expense. You must provide a current statement from the provider.

	Add/Remove?	Amount Paid	Frequency	Name of Provider	Address of Provider
Expense 1
Expense 2

Comments:

I certify that the information given to the Housing Authority of San Angelo on this form is true and complete to the best of my knowledge and believe. I understand that false statements or information are grounds for termination of housing assistance. I understand that I can be fined or imprisoned for furnishing false or incomplete information.

I also understand that I must provide proof of all information provided either by mail, email, or upload to this document.

Add/Remove?

Name of Account Holder

Type Of Account

Account Number

Current Blance

Name of Bank

Title 18, Section 1001 of the United States Code, stated 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 *

Clear

Date Form Completed *

MM / DD / YYYY

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