050356 EM 1.8.2021
Income Change Form
Housing Authority program participants are required to report all changes within 14 days of the change.
Return this form with verifications
You may also report a change through our Online Portal on our website www.hacosantacruz.org. Call the
Housing Authority for a registration code to use the online portal.
Head of Household: Last 4 digits of SS: Phone Number:
Name of the household member experiencing a change:
You must provide the following verification
□ New Job
□ Letter from Employer stating date of termination
□ Letter from Employer stating start date, pay rate,
hours worked per week, or your most recent pay stub
□ Less money / hours at existing job
□ More money / hours at existing job
□ 3 consecutive pay stubs and
□ Date change went into effect
□ Letter from Employer stating pay rate, hours worked
per week and date change went into effect
□ Lost/decreased public assistance / benefit
□ New / increased public assistance / benefit
□ All pages of the notice from the agency verifying
change and effective date
□ I am applying for or receiving any other income:
o Social Security (SS) / Supplemental
Security Income (SSI)
o Welfare or Cash Aid
o Regular Contributions from anyone
□ Award letter or Denial Letter
□ Letter from provider verifying amount and frequency.
Letter should be signed, dated and include contact
information of provider
Additional changes: OTHER: ______________
□ Documentation from the source of this change
Due to the volume of changes reported, it may take a long time to process your change. Once all information has been
received and verified, the Housing Authority will determine whether or not your housing assistance will change. In some
cases, increases or decreases may be retroactive due to a delay in reporting or processing. You will be notified in writing
regarding the details of the results of your reported changes as soon as it has been completed. If you have an increase in
household income, expect to pay an increase that is approximately 30% of your increased income.
I do hereby swear and attest that all of the listed information and documents provided are true, complete, and correct,
that there have been no other changes to my family composition or income.
WARNING – TITLE 18 SECTION 1001 OF THE UNITED STATES CODE STATES THAT ANY PERSON WOULD BE GUILTY OF A
FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR
AGENCY OF THE UNITED STATES.
Print Head of Household Name Signature of Head of Household Date