Saha Change Of Income Form – Fill Out and Use This PDF

CHANGE OF INCOME PROCESS

Please complete the enclosed packet so we may process your change of income request. As a reminder, it is the family’s responsibility to report any and all changes in household income within ten business days of the change. Please provide all information needed that applies to your type of change.

When submitting a change of income, you MUST include the following.

Change of Income Request form (attached)

Release of information forms – HUD-9886 and SAHA Non-Employment Authorization (attached)

Proof of any change in household income since last reported to SAHA, including the employer’s contact information and 4 paycheck stubs (if change is due to increased or decreased employment income), or a letter from the employer indicating the amount and frequency of pay

Letter on company letterhead indicating date of separation (if you are no longer employed)

If the application or authorization for release of information is not signed, the processing of the change in income will be delayed.

You may also have to include one or more of the following, if applicable.

Unemployment benefits award letter

Veterans Affairs award letter

TANF award letter

Worker’s Compensation benefit statement

SS/SSI award letter – must provide the actual award letter sent by the Social Security Administration

Pension statement

Child support court order, a 12-month child support print out, or a notarized letter indicating child support amount

Statement of income (you may use attached form)

Direct child support statement (must be signed by contributor and notarized)

General contributions statement (must be signed by contributor and notarized)

Expenses such as childcare, or medical expenses should include related documents, receipts, and a payment history print out for the past year. Childcare expenses should include the name and address of the daycare.

Completed change of income forms must be submitted using one of the following methods:

FAX (210) 477-6206

E-mail HCVchanges@saha.org

Hand delivered to 820 S. Flores St., San Antonio, TX 78204

Mail to the following address:

San Antonio Housing Authority

Attn: Assisted Housing Programs, COI

820 South Flores

San Antonio, TX 78204

*Failure to complete packet or submit supportive documentation could result in the denial and/or delay of the COI request.

Any individual with a disability or other medical need who requires accommodation with respect to this correspondence should contact the San Antonio Housing Authority at (210) 477-6205.

Todos los individuos con alguna incapacidad u otra necesidad médica que requieran algún acuerdo con respecto a este formulario, deberán contactar a la Autoridad de Vivienda de San Antonio en el Tel. (210) 477-6205.

STATEMENT

Name:

Last 4 of SSN:

Address:

City:

State:

Zip:

Phone Number:

Email Address:

Statement (Please Print):

Warning: 18 U.S.C. 1001 provides that whoever knowingly and willfully makes or uses a document or writing containing a false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of a department or an agency of the United States shall be fined not more than $10,000 or shall be imprisoned for not more than five years or both.

By signing below, I am certifying that the information above is true and correct. I also acknowledge that it is my responsibility to report any and all changes in the income and/or family composition of my household within ten days of the change in writing.

Signature

Date

In the presence of (Signature)

Any individual with a disability or other medical need who requires accommodation with respect to this form should contact the San Antonio Housing Authority at (210) 477-6205.

Equal Housing Oppor t un it y  Equal Oppor t un it y Em ploy er

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Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

Signatures:
_____________________________________________	______________
Head of Household	Date
___________________________________________		__________________________________________________	________________
Social Security Number (if any) of Head of Household		Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Spouse	Date	Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Other Family Member over age 18	Date	Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Other Family Member over age 18	Date	Other Family Member over age 18	Date

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Original is retained by the requesting organization.

ref. Handbooks 7420.7, 7420.8, & 7465.1

form HUD-9886 (7/94)

Authorization for Release of Information

(Non-Employment)

RE:

Head of Household

HOH SSN Last 4

Street Address

SAHA Representative

To process your Change of Income request, we must verify the change. By signing this form, you are authorizing the San Antonio Housing Authority to obtain verification of the change you reported regarding any of the following.

Temporary Assistance for Needy Families (TANF)

Child Support

Veteran’s Benefits

Workman’s Compensation

Domestic Employment

Full Time Student Status

Pension

Note: This authorization is in addition to HUD Form 9886, which you sign each year at recertification and is valid for 15 months. HUD Form 9886 is applicable to salary and wages from current or previous employers; wage and unemployment compensation; Social Security wage, employment, and retirement information; and unearned income (interest and dividends) reported by financial institutions.

This form can be sent to any applicable third-party source regarding the information specified above to verify the change you report. This information will only be used to determine that your housing assistance benefits are set at the correct level.

Applicant/Participant Release (MUST be signed by all household members, age 18 and over)

I hereby authorize the release of information pertaining to the above listed benefits or sources of income to the San Antonio Housing Authority (SAHA).

Head of Household Signature: _______________________________________	Date: ___________________
Household Member Signature: _______________________________________	Date: ___________________
Household Member Signature: _______________________________________	Date: ___________________
Household Member Signature: ______________________________________________	Date: ______________________

Any individual with a disability or other medical need who requires accommodation with respect to this form should contact the San Antonio Housing Authority at (210) 477-6205.

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