HCV Interim Change Form

RCRHNC Logo.

Roanoke Chowan Regional Housing Authority
8:30 am - 5:00 pm Monday-Thursday
8:00 am - 11:30 am Friday
Except Holidays
205 Tinsley Way, Gaston, NC 27832
252.537.1051

Fields marked with * must be completed or form will not submit.

For non-applicable fields enter N/A.

Dear Client/Participant:
The following information is needed ONLY if there has been a change in your income, employment, household composition, childcare, and/or child support. It is your responsibility to report all changes to your household, in writing, within ten (10) days of the event of change. No changes will be accepted by phone.
You must submit proper documentation along with this form. Failure to submit this information in a timely manner will result in the delay of your change being processed, and if an overpayment has occurred you may be required to reimburse the Housing Authority. Failure to report changes could result in the termination of your Section 8 benefits.
You are required to continue paying your current portion of the rent until an Interim change has been completed and a written notice has been sent to both you and the landlord indicating the new rental amounts and the effective dates.*

I understand.

First Name*

Last Name*

Social Security Number*

Head of Household First Name*

Head of Household Last Name*

Street Address*

City*

State*

ZIP Code*

Home Phone Number*

Cell Phone Number*

Work Phone Number*?

Income or Employment Changes

For Income Changes: Attach all of the following documentation that applies to your household:
- Proof of employment or loss of employment from employer.
- Proof of Unemployment or loss of unemployment.
- Proof of Social Security Income/Veterans Income/Retirement Pension
- Proof of Annuities, Stocks, CD's, Bonds, Money Market Accounts
- Proof of Child Support or non-Support
- Written documentation for any other income received

Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open".

For assistance in uploading these forms call #_ Ext. _

I am reporting the following changes: (attach proof of change above)
*

New Employment

Return to Employment

Termination of Employment

Increase or Decrease with Current Employment

Changed Jobs (attach written proof)

Social Security or SSI

Pension

TANF (Temporary Assistance for Needy Families)

Contribution Income (attach notarized statement from anyone helping you pay your bills; must include the amount given each month, their full name and address, and a contact number)

N/A

New Employment Start Date*?

Return to Employment Date*?

Termination of Employment Date*?

Social Security or SSI Change*

New

Increase

Decrease

Ended

N/A

Pension Change*

New

Increase

Decrease

Ended

N/A

TANF Change*

New

Increase

Decrease

Ended

N/A

Contribution Income Change*

New

Increase

Decrease

Ended

N/A

Household Composition Changes

I am: *

adding a member (attach requirements)

removing a member (attach Move-Out Form)

N/A

- To add a child: you must supply Birth Certificate, Social Security Card, and proof of legal or physical custody (if the child is not yours or not a child of a current household member on your voucher)
- To add an adult: The adult must be present with you to sign authorizations and supply Birth Certificate, Social Security Card, Picture ID and you must have a letter from your landlord that they would approve this person to be added to the lease.
- To remove a household member: you must complete a Move-Out Form and supply the address to where the removed person will reside; a lease or another approved document must be submitted to show the new address where they will reside.

Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open".
?

New Household Composition is as follows:

Please list all household members starting with the head of household, continuing oldest to youngest.

Household Member #1

Household Member #1 First Name*?

Household Member #1 Last Name*?

Household Member #1 Middle Initial*

Household Member #1 Relationship (to Head of Household)*

Household Member #1 Sex*

Household Member #1 Age*

Household Member #1 Social Security Number*

Household Member #1 Date of Birth*

Household Member #2

Household Member #2 First Name

Household Member #2 Last Name

Household Member #2 Middle Initial

Household Member #2 Relationship (to Head of Household)

Household Member #2 Sex

Household Member #2 Age

Household Member #2 Social Security Number

Household Member #2 Date of Birth

Household Member #3

Household Member #3 First Name

Household Member #3 Last Name

Household Member #3 Middle Initial

Household Member #3 Relationship (to Head of Household)

Household Member #3 Sex

Household Member #3 Age

Household Member #3 Social Security Number

Household Member #3 Date of Birth

Household Member #4

Household Member #4 First Name

Household Member #4 Last Name

Household Member #4 Middle Initial

Household Member #4 Relationship (to Head of Household)

Household Member #4 Sex

Household Member #4 Age

Household Member #4 Social Security Number

Household Member #4 Date of Birth

Household Member #5

Household Member #5 First Name

Household Member #5 Last Name

Household Member #5 Middle Initial

Household Member #5 Relationship (to Head of Household)

Household Member #5 Sex

Household Member #5 Age

Household Member #5 Social Security Number

Household Member #5 Date of Birth

Household Member #6

Household Member #6 First Name

Household Member #6 Last Name

Household Member #6 Middle Initial

Household Member #6 Relationship (to Head of Household)

Household Member #6 Sex

Household Member #6 Age

Household Member #6 Social Security Number

Household Member #6 Date of Birth

Child Care Changes

Child Care Change*

New

Increase in Monthly/Daily Fee

Decrease in Monthly/Daily Fee

Change of Child Care Provider (attach proof of change)

Additional Child Care Provider (attach required proof)

N/A

You must provide your 6 most recent receipts and a statement from your child care provider with your provider’s full mailing address and telephone number. (A valid child care verification form from DSS along with receipts will also suffice).

If your child care is provided by a non-traditional source (for example: a family member, friend, or neighbor) the person providing childcare must provide a written, notarized statement detailing the days, hours, and pay received for providing the service along with your 6 most recent receipts. You and your provider will be asked to show proof (tax return) that childcare has been paid and claimed. If unable to provide, childcare will not be counted.
Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open".

Child Support Changes

For Changes in Child Support:
- You must provide a twelve (12) month printout of child support. A six (6) month average of payments will be counted.

Child Support:
- Court documentation of change
- DSS statement of change
- Notarized, written statement of change from the parent providing the support; not court ordered (include amount, full name and address, and contact number)

Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking "Open".

I certify that I am giving true and complete information, according to my knowledge, and that all the information provided on household composition, household income and assets, and items for allowances and deduction, is accurate.*

I certify.

I understand that knowingly supplying false, incomplete, or inaccurate information is punishable under Federal or State criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance.*

I understand.

Signature*

Date*

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