Client Information

INCOME CHANGE REQUEST FORM
!FOR CURRENT CLIENTS ONLY!
PLEASE BE ADVISED, IF YOU ARE LEAVING YOUR CURRENT EMPLOYER TO START NEW EMPLOYMENT, YOU MUST REPORT NO LONGER WORKING AT YOUR CURRENT PLACE OF EMPLOYMENT OR WE WILL ASSUME YOU ARE STILL EMPLOYED WITH YOUR PREVIOUS EMPLOYER!

* Indicates required field

Head of Household Name: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number: *

Date: *

PLEASE BE ADVISED WHEN COMPLETING THIS FORM ONLINE, YOU WILL HAVE TO EITHER EMAIL DOCUMENTS TO [email protected] SUPPORTING YOUR CHANGE/ REQUEST OR IF YOU ARE UNABLE TO EMAIL THE DOCUMENTS YOU WILL BE REQUIRED TO MAIL/ BRING THEM INTO THE OFFICE AS SOON AS POSSIBLE.
PLEASE BE ADVISED NO CHANGE CAN BE OFFICALLY MADE WITHOUT SUPPORTING DOCUMENTATION.

Are you reporting NEW income, a change in your current income, child care or household composition? *

Yes No

IF YES PLEASE EXPLAIN IN THIS BOX- IF STARTING A NEW JOB OR SWITCHING JOBS, PLEASE LIST THE NAME AND LOCATION SO WE ARE ABLE TO CONTACT THEM AND VERIFY *

Are you reporting a LOSS in income? *

Yes No

IF YES PLEASE EXPLAIN IN THIS BOX *

Are you requesting to ADD a household member? *

Yes No

PLEASE BE ADVISED WHEN REQEUSTING TO ADD SOMEONE TO YOUR HOUSEHOLD; We will need a copy of their state ID/ license, birth certificate and social security card. We will also need them to sign an authorization form at time of request submission.

IF YES PLEASE EXPLAIN IN THIS BOX *

Are you REMOVING a household member? *

Yes No

PLEASE BE ADVISED WHEN REMOVING A HOUSEHOLD MEMBER; We will need proof of residency else where for this household member; either a bill/ license with new address OR the lease.

IF YES PLEASE EXPLAIN IN THIS BOX *

Print name: *

Date: *

Submit

HCV re-cert Application
File Size:	99 kb
File Type:	docx

Download File

Leisure Acres re-cert Application
File Size:	52 kb
File Type:	docx

Download File

Authorization Form
File Size:	61 kb
File Type:	pdf

Download File

Emergency Contact Form
File Size:	41 kb
File Type:	pdf

Download File

EIV Certification
File Size:	97 kb
File Type:	pdf

Download File

CURRENT CLIENT FORMS​& INFORMATION

INCOME CHANGE REQUEST FORM!FOR CURRENT CLIENTS ONLY!PLEASE BE ADVISED, IF YOU ARE LEAVING YOUR CURRENT EMPLOYER TO START NEW EMPLOYMENT, YOU MUST REPORT NO LONGER WORKING AT YOUR CURRENT PLACE OF EMPLOYMENT OR WE WILL ASSUME YOU ARE STILL EMPLOYED WITH YOUR PREVIOUS EMPLOYER!​

CURRENT CLIENT FORMS
& INFORMATION

INCOME CHANGE REQUEST FORM
!FOR CURRENT CLIENTS ONLY!
PLEASE BE ADVISED, IF YOU ARE LEAVING YOUR CURRENT EMPLOYER TO START NEW EMPLOYMENT, YOU MUST REPORT NO LONGER WORKING AT YOUR CURRENT PLACE OF EMPLOYMENT OR WE WILL ASSUME YOU ARE STILL EMPLOYED WITH YOUR PREVIOUS EMPLOYER!