PH Interim Change of Income

Page 1 of 5

This form is being completed in(*)

English

Spanish

Invalid Input

Process for Requesting a Change in Household Income

BMHA requires Public Housing tenants to report interim changes within ten (10) calendar days of when the change occurs in writing. Failure to comply with this requirement may result in an eviction being filed against the tenant and/or retroactive rent charges. Also, BMHA is unable to accept any change in the household income if the income change will not last at least thirty (30) days. In order to have a change in household income processed, tenants are required to complete a “Change in Household Income Request” form. **ALL INCOME CHANGES MUST RECEIVED BY BMHA NO LATER THAN THE CLOSE OF BUSINESS (4:30PM) ON THE 23^RD OF EACH MONTH.**

MANDATORY DOCUMENTATION

Change in Household Income Request form (following)

VERIFICATION, IF REPORTING A CHANGE IN EARNED (EMPLOYMENT) INCOME:

Increased or decreased household earned income, attach the following:
- Paycheck stubs
- Letter on employer’s letterhead listing start/end date, hours worked, pay rate and frequency of pay.
Employment Termination/Separation (*paycheck stubs are not an acceptable form of verification of employment ending*)
- Letter on employer’s letterhead indicating date of termination/separation, and anticipated return date if applicable.
In tenants are unable to obtain the required verification, as listed above, documentation of their attempts much be provided to BMHA

*Only with approved documentation of a tenant’s inability to obtain the mandatory verification, a notarized statement may be used as a “Self-Certification” for the purpose of verifying current household income.

VERIFICATION, IF REPORTING A CHANGE IN UNEARNED INCOME:

Most recent award letter from:
- Butler County Job and Family Services (OWF/TANF/FOOD STAMPS)
- Social Security Administration (SS/SSI Benefits)
- State Unemployment Compensation Benefits
- Worker’s Compensation Benefit Statement
- Current Pension Benefit Statement (i.e. Retirement, Veteran’s Administration etc.)
12 month child support printout printed within the last thirty (30) days
Notarized Zero Income statement

*When reporting a change in Childcare and/or Medical expenses, please attach applicable verification to include: 12-month payment history, payment receipts, etc.

General Release Form

I hereby authorize/direct The Hamilton/Middletown Police Department, or any other Federal, state, or local agency, organization, business, or individual, to release any information needed to determine my eligibility for housing or continued occupancy with Butler Metropolitan Housing Authority.

I authorize you to release as applicable, any credit, financial, employment information relating to my previous housing tenancy, credit information, my personal or family’s conduct including criminal records or drug abuse. This information is to be used solely by Butler Metropolitan Housing Authority to determine whether or not I qualify as an applicant or for continued occupancy as a resident. It will not be disclosed outside the agency without my consent, but may be viewed by authorized employees or representatives of the U.S. Department of HUD, as applicable.

I understand, depending on Butler Metropolitan Housing Authority’s policies and requirements, that verification of information for household or may be required. I agree that a photocopy of this authorization may be used for the purposes stated above.

Signature Head of Household(*)

Invalid Input

Signature Co-Head/Other Adult

Invalid Input

Signature Other Adult

Invalid Input

Signature Other Adult

Invalid Input

No Income Acknowledgement

If you have income, do not complete this section. Scroll to the botton and click Next.

Name

Invalid Input

Address

Invalid Input

City

Invalid Input

State

Invalid Input

Zip Code

Invalid Input

I (we) hereby certify that I (we) do no individually receive income from any of the following sources:

Wages from employment (including commissions, tips, bonuses, fees, etc)
Income from operation of a business
Rental income from real or personal property
Interest or dividends from assets
Social Security payments, annuities, insurance policies, retirement funds, pensions, or death benefits
Unemployment or disability payments
Public Assistance payments
Periodic allowances such as alimony, child support, or gives received from persons not living in my household
Sales from self-employed resources (Avon, Mary Kay, Skaklee, etc)
Any other source not named above

I (we) currently have no income of any kind and there is no imminent change expected in my financial status or employment status during the next 12 months

I (we) will be using the following sources of funds to pay for rend and other necessities

Invalid Input

Amount of Funds (Monthly)

Invalid Input

Signature of Applicant/Participant

Invalid Input

Employment Verification

Employer Name(*)

Invalid Input

Employer Address(*)

Invalid Input

Employee Name(*)

Invalid Input

Social Security #(*)

Invalid Input

Phone(*)

Invalid Input

Fax

Invalid Input

(*)

I do hereby authorize you to release the information requested below directly to the Butler Metropolitan Housing (BMHA) Leasing Department

Invalid Input

Employee Address(*)

Invalid Input

Employee Signature(*)

Invalid Input

Follow us

Follow us

Process for Requesting a Change in Household Income

MANDATORY DOCUMENTATION

VERIFICATION, IF REPORTING A CHANGE IN EARNED (EMPLOYMENT) INCOME:

VERIFICATION, IF REPORTING A CHANGE IN UNEARNED INCOME:

Change in Household Income Request

Increase in household earned (employment) income (Check all that apply):

Decrease in household earned (employment) income (check all that apply):

Additional Change(s) - Please check all that apply

General Release Form

No Income Acknowledgement

Employment Verification

NOTE: Please only click Submit ONE TIME. It may take up to 1 minute for the file to be submitted.

Let's Connect

Butler Metro HA

4110 Hamilton Middletown Rd., Hamilton OH 45011-6218

Administrative & Leasing Office

© Copyright 2020 Butler Metropolitan Housing Authority, All Rights Reserved | Website by ADAGO Marketing

Login Form