GEORGIA RENTAL ASSISTANCE
RECERTIFICATION BASED ON MONTHLY INCOME
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Please complete one form for each adult household members (age 18 and up) for the
recertification of income based on a monthly income calculation. This form should be
completed and uploaded where required. In cases where the household member does
not have income, or is unable to provide documentation of their income, please use the
Income Documentation Waiver form. Note that every adult household member (age 18
and up) MUST complete one of the income recertification forms (Monthly or Annual)
and/or the Income Documentation Waiver form.
Full Name: ____________________________________ Date of Birth: _____/____/_______
Address: ___________________________________________ Apt No._________________
City/State/Zip: _______________________________________
Email Address: _____________________________ Contact Phone No. ________________
Please attach one, or a combination of the following, for the previous three (3) consecutive
months:
Documents evidencing monthly income. This can be a: wage statement, interest statement,
or unemployment compensation statement.
If you do not have the above documentation, please attach the following information for
the previous three (3) consecutive months:
• If employed: pay stubs, third party verification from employer, or a letter from employer
indicating reduced pay,
• Documentation of cash assistance such as Social Security income, unemployment
benefits, worker’s compensation (excluding lump sum distributions), or public assistance
benefits,
• Documentation of child support or alimony payments,
• TANF, SSI, or a determination letter from one of these programs dated after January 1
st
of the current year,
• Documentation of any income received for self-employment, including documentation of
income from the operation of a business or profession, or direct payments for services
• Bank statements, and/or
• Documentation of Social Security, annuities, retirement income, pensions, disability or
death benefits and other similar types of periodic or monthly receipts, excluding
benefits received by anyone 17-years old or under.
