HCV Personal Declaration Packet

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WARNING!! TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

Reason for Completing This Form

(*)

Reporting a change of income or family size

Briefing - Application/Port Appointment

Annual Recertification

Contract Signing

Relocation

Informal Hearing

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You have selected a change in your household income or family size. Please explain:

(*)

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Head of Household

Name(*)

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Street Address(*)

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City(*)

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Zip Code(*)

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Phone Number(*)

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Alternate Phone Number

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Email Address

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Statement of Household Size

Please list ALL Persons who reside in your household (including yourself). You must use the correct legal name for each member as it appears on their Social Security card.

Full Name (head of household)(*)

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Relationship(*)

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Sex(*)

Male

Female

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Social Security #(*)

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Date of Birth(*)

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Age(*)

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Place of Birth(*)

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Full Name - 2nd Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 3rd Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 4th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 5th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Fulll Name - 6th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 7th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 8th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Full Name - 9th Person

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Relationship

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Sex

Male

Female

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Social Security #

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Date of Birth

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Age

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Place of Birth

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Household Information

Have you or any household member been convicted of any drug-related or violent criminal activity within the last 12 months?(*)

Yes

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Please explain:(*)

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Are you or any other family member of your household disabled?(*)

Yes

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Please list disabled members:(*)

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Are you or any other adult member of your household claiming ZERO income?(*)

Yes

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Note: ALL adults claiming ZERO income MUST complete a notarized statement of zero income.

Please list those adult members claiming ZERO income:(*)

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Are you or any member of your household over the age of 18 a full time student?(*)

Yes

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Student Name - 1st Person(*)

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School Name and Address(*)

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Full or Part Time Student?(*)

Full

Part Time

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Student Name - 2nd Person

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School Name and Address

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Full or Part Time Student?

Full

Part Time

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Statement of Assets

You must select YES or NO for each Question

ASSETS

Do you or any household member have a checking, savings account, CDs, Money Markets, Stocks, IRA's, Trust Funds or any retirement accounts?(*)

Yes

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Household Member(*)

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Bank Name(*)

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Type of Account(*)

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Value / Balance(*)

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Household Member

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Bank Name

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Type of Account

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Value / Balance

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Household Member

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Bank Name

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Type of Account

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Value / Balance

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PROPERTY

Do you or any household member currently own real estate, rental property, land contract, or any other real estate? (This includes a personal residence, mobile home, vacant land, vacation homes or commercial property.)(*)

Yes

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Household Member(*)

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Type of Property / Asset(*)

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Value(*)

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Have you or any household member disposed, sold or given away any property or assets within the last 2 years?(*)

Yes

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Please explain:(*)

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Statement of Eligible Expenses

You must select YES or NO for each Question

CHILD CARE EXPENSES

Do you pay childcare to allow you to go to work or school?(*)

Yes

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What is the amount you pay?(*)

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Frequency(*)

Weekly

Bi-Weekly

Monthly

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Name and address, phone / fax of childcare provider(*)

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CARE ATTENDANT / MEDICAL EQUIPMENT EXPENSES

Do you pay for a care attendant or for any medical equipment or any disabled / handicapped member of the family to permit that person or someone else in the family to work?(*)

Yes

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What is the amount you pay?(*)

Invalid Input

Frequency(*)

Weekly

Bi-Weekly

Monthly

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Name and address, phone / fax of care provider(*)

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MEDICAL EXPENSES

Do you pay out of pocket for any medical expenses such as medical bills, prescriptions, medical insurance, or have a medical spend down with Jobs and Family Services?(*)

Yes

Invalid Input

What is the amount you pay?(*)

Invalid Input

Frequency(*)

Weekly

Bi-Weekly

Monthly

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If you are elderly or disabled and have out of pocket medical expenses, you MUST provide proof of these expenses for the laast 12 months in order to receive a deduction.

CERTIFICATION / ACKNOWLEDGEMENT

I/WE certify that the above information is true to the best of my knowledge and belief. I/WE understand that the above information is being collected to determine the continuation of eligibility for Section 8 assistance. I/WE authorize the HCV office to verify all information provided on this declaration and to release information to appropriate Federal, State, or local agencies. I/WE understand that false statements or information could result in the termination of any Section 8 assistance and are punishable under Federal Law. I understand that all changes in income must be reported to the HCV, inwriting within 10 days. I agree that the below signature will be the electronic representation of my signature for all purposes-just the same as a pen and paper signature.

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Head of Household(*)

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Spouse/Other Adult

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Other Adult

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Other Adult

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Statement of Household Income

All Adult household members MUST complete a Statement of Income. Please repeat this form for each Adult household member.

Full Name(*)

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Are you employed?(*)

Yes

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Employer Name(*)

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Employer Address(*)

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Phone(*)

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Fax

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Hourly Rate of Pay(*)

Invalid Input

No. of Hrs Per Week

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Payment Frequency

Weekly

Bi-Weekly

Monthly

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Amount of Weekly Tips

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Amount of Weekly Commission

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Weekly Bonus

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Do you have more than one Employer?(*)

Yes

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Name of 2nd Employer(*)

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Employer's Address(*)

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Phone(*)

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Fax

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Hourly Rate of Pay(*)

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No. of Hrs Per Week

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Payment Frequency

Weekly

Bi-Weekly

Monthly

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Amount of Weekly Tips

Invalid Input

Amount of Weekly Commission

Invalid Input

Weekly Bonus

Invalid Input

Do you receive Child Support or Alimony Payments?(*)

Yes

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I receive child support from (what county)(*)

Invalid Input

In the amount of (the amount you actually receive)(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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I receive child support from (what county)

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In the amount of (the amount you actually receive)

Invalid Input

Payment Frequency

Weekly

Bi-Weekly

Monthly

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I receive child support from (what county)

Invalid Input

In the amount of (the amount you actually receive)

Invalid Input

Payment Frequency

Weekly

Bi-Weekly

Monthly

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Do you receive Unemployment Benefits?(*)

Yes

Invalid Input

What is the amount?(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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Do you receive Worker's Compensation?(*)

Yes

Invalid Input

What is the amount?(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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Do you receive a pension?(*)

Yes

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What is the amount?(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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Do you or anyone in household receive cash contributions from an individual or agency?(*)

Yes

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From whom?(*)

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What is the amount?(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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Do you or anyone in household receive regular Social Security or SSI?(*)

Yes

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Name(*)

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Monthly Amount(*)

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Name

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Monthly Amount

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Name

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Monthly Amount

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Do you receive assistance from Jobs and Family Services?(*)

Yes

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Do you receive Food Stamps?(*)

Yes

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Monthly Amount(*)

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Do you receive Cash Assistance?(*)

Yes

Invalid Input

Monthly Amount(*)

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Are you under Sanction?(*)

Yes

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What is your pre-sanction amount?(*)

Invalid Input

Do you receive any income from any other source not listed previously?(*)

Yes

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From whom?(*)

Invalid Input

Monthly Amount(*)

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Payment Frequency(*)

Weekly

Bi-Weekly

Monthly

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