EmailMe Form - HCV: Interim Re-Examination

If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the housing authority.

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

CERTIFICATION: By signing below, I certify that all the information on this form is true and complete. No other changes need to be reported at this time regarding my household income, composition, expenses, or assets. I understand that the HASA does not know of any changes in the interim period between annual reexaminations unless reported or found on a discrepancy report. It is my duty to report all changes as required. I understand that if the HASA determines this change to not require processing under HOTMA regulations, I still have the duty to report.

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

WARNING:

Name of Head of Household *

First Last

Email

Mobile Phone

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

Home Phone

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

Work Phone

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

Message Phone

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

Which changes are you reporting? *

Working/Earned Income: Complete this section only if you are adding or removing earned or working income. To add income, you must provide a current employer statement to include hire date, rate of pay, hours worked, and contact information OR 2-3 current and consecutive check stubs. To remove income, you must provide an employer statement with the last date worked and contact information.

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

Supplemental Benefits: Complete this section if you are adding or removing benefits. You must provide a current award letter or statement dated within the last 60-120 days.

	Add/Remove?	Name of Person Receiving	Amount Received	How Often Received
TANF
Child Support
SS/SSI
SNAP
Unemployment
Pension / Retirement
Worker's Comp
Self-Employed
Other

Nonwage Income: Complete this section if you are adding or removing contributions or other nonwage income not listed above. You must provide a current statement to include amount, how often, and contact information.

Does anyone outside your household pay any of your bills, give you money, etc? *

If yes, please explain:

Household Composition: Complete this section only if you are adding or removing persons from the household or are changing the status of one of the household members relationship. If changing the status of relationship, please indicate in the relation column, i.e. change to spouse, change to full-time student, etc. To add or remove a household member, you will be asked to provide additional documentation as applicable. Please discuss with the caseworker.

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

Are you or any adult in the household a part-time or full-time student? *

If yes, does the student receive financial aid assistance?

Childcare: Complete this section only if you are adding or removing child care expense information. You must provide a child care provider statement to include the information below. Note: to qualify for this expense, you must be working or going to school full-time.

	Add/Remove?	Amount Paid	How Often Paid	Name of Provider	Address of Provider	Child(ren) Names
Child Care Expense 1
Child Care Expense 2

Medical Expenses: Complete only if the Head of Household, Spouse, or Co-head is 62 years of age or older OR disabled. Note: When reporting medical expenses including medical bills, prescriptions, etc., please provide a 12-month printout showing the payment history for consideration.

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

Assets: Complete this section only if you are adding or removing assets. You must also provide a current statement or relevant verification of the asset.

Do you or any household member have any current interest in real property at the time of this reporting? *

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:

If you have additional information to report to the HASA not listed elsewhere on this form, please describe in the box provided.

Add/Remove?

Name of Person Receiving

Amount Received

How Often Received

Contributors Name

Contributor's Phone Number

Nonwage Income 1

Nonwage Income 2

Nonwage Income 3

Nonwage Income 4

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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