Facts to Remember
1. Changes must be reported within 10 days
2. Changes must be reported by the 15
th
of the month, to be reviewed for the following month
3. Supporting documentation must be submitted with this form. If you are reporting that:
A reduction in work hours; you must supply 3 current paystubs or letter from employer
A loss of income; you must supply the termination letter (letter stating you no longer receive
income)
A household member moved out; you must supply a copy of your updated lease showing the
individual no longer resides with you
Requesting to add a minor; you must supply Birth Certificate and SS card (children cannot be
added without these documents)
Additional Income; Supply 3-6 current paystubs or benefit letter
4. Continue to pay the same amount of rent. Once a change is processed you and
your landlord will be notified of the new rent amount, as well as the effective date of
the change.
If you require a reasonable accommodation in order to access the Project Based Voucher Program, please advise your case worker.
I/We certify that the information given to the Project Based Voucher program on household composition, income, net family assets, and
allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or
information are punishable under Federal Law and or State Law. I/We also understand that false statements or information are grounds for
termination of housing assistance and termination of tenancy.
______________________________________ __________________ _______________________________ ______________
Signature of Head of Household Date Signature of Spouse Date
________________________________________ __________________ ______________________________ ______________
Other Family Member over age 18 Date Other Family Member over age 18 Date
