050803 10/09/03 ab
TIMESHEET
Community Service or Self-Sufficiency Activities
Please complete one timesheet for each adult household member who is required to perform the community service
requirements. You may complete your community service activities at any agency that provides activities that are “a
public benefit, and that serve to improve the quality of life, enhance resident self-sufficiency, or increase resident
self- responsibility in the community.” Political activities may not be counted as community service. Examples of
eligible Community Services activities: schools, hospitals, local community (non-profit) agencies, homeless shelters,
recreations centers, senior centers, food banks. You choose where you perform your volunteer services.
You may also participate in economic self-sufficiency activities. These include “job training, employment
counseling, work placement, basic skills training, education (junior college, college), English proficiency, workfare,
financial or household management, apprenticeship, and any program necessary to ready a participant for work
(including a substance abuse or mental health treatment program), or other work activities.”
A minimum of 8 hours per month, every month, must be completed for each family member who is not exempt and
is required to perform these activities:
(Total hours required per year: 12 months X 8 hours per month = 96 hours)
Name:____________________________________________ Head of Household SS#:_____________________
Description of Activities Completed:________________________________________________________________
Name of agency/school: __________________________________________________________________________
Agency/school Address:_________________________ City:_______________ State: _____ Zip Code: ________
Contact Person: ____________________________________ Phone: ___________________________________
List dates and number of hours performed per month, each month. You need 96 hours per year.
Month/Year Number of hours Month/Year Number of hours Month/Year Number of hours
By signing below, I certify that I have completed the activities described above and I authorize the Housing
Authority to contact the agency listed to verify my activities. I understand that failure to comply with the
Community Service and Self-Sufficiency requirements may result in non-renewal of my lease.
________________________ ___________ ________________________ ___________
Tenant Signature Date Community Service, Date
Economic Self Sufficiency Agency Signature
You may copy this form if you need more space
