Change of Circumstance Form (RA-105)

NEW POLICY ON INCREASE AND DECREASES

Any Change of Circumstance form that is submitted with verifications attached will be processed immediately. If verifications (when needed) are not attached, there will be a 10 business day window to turn in needed documentation. After 10 business days, if needed verifications are not provided, the Change of Circumstance form will be rejected and the client will need to re-submit.

Rent Increases

THA will not perform interim increases in rent between regularly scheduled recertification, except for:

If an additional family member with income is added to the household
“Zero” income” families reporting new income.

Rent Decreases

Interim reductions in rent will be made, but limited to reduce administrative costs to THA and to provide incentives to employed families to remain employed. THA staff will compare the current income in the system vs. the reported income when determining the 20% decrease. For households who are not elderly or disabled, interim adjustments will be limited as follows and require MTW flexibility:

The rent reduction will only be implemented if the adjusted income will decrease by 20% or more.
No reduction based upon loss of job will be processed until THA receives documentation of eligibility or ineligibility for unemployment benefits;
New rent portion will only be processed if the decrease in income is expected to last for longer than ninety (90) days
Decreases in public assistance income that are the result of a finding of fraud or a failure to comply with work/school requirements will not be processed

Changes reported after the 20^th of the month will not take effect until the second month following reporting.

*It is the family’s responsibility to report any income or family composition changes. Failure to do so will be considered fraud. This could lead to termination or a repayment agreement.

The goal of the “no increase” policy is to encourage you to maintain or increase earnings and save the amount that would have been charged due to an increase in rent.

_______________________

[1]Death, Divorce, or a documented criminal activity that brings about the need to remove the person from the household.

Please check to acknowledge that you understand the above statement *

I understand

Head of Household:

Place of Residence or Program: *

First Name: *

Last Name: *

Unit Address: *

Phone Number: *

Last Four Digits of Head of
Household's Social Security #: *

Email Address:

**Email is not required,

but entering an email will

speed up the process.

Are you the Head of Household?: *

Reason for Filling out Form *

Head of Household Does Not Have Access to a Computer

Head of Household Does Not Use a Computer

Other Other

What Type of Change is This? Please select ALL the changes you want to report. More than one may apply: *

To Port Out, you must complete the Request to Port Out Form instead.

Learn more on our Moving & Portibility page.

Name prior to change: *

New Name: *

Reason for name change: *

Please attach a copy of your mortgage statement here:

Are you or an adult household member currently a student? (Vocational, Technical, Community College, University, or other post-secondary education) *

Yes

No

Are you or an adult household member a full time or part time student? *

Full time

Part Time

Full time students must provide the following:

Student Status Verification Form (Available at THA)
Financial Aid Award Letter
Tuition Detail

Part time students must provide the following:

Student Status Verification Form (Available at THA)

Do you have any additional students to add? *

Yes

No

How many additional students need to be added? *

Additional Student #1's Name: *

Is he/she a full time or part time student? *

Full time

Part Time

Full time students must provide the following:

Student Status Verification Form (Available at THA)
Financial Aid Award Letter
Tuition Detail

Part time students must provide the following:

Student Status Verification Form (Available at THA)

Additional Student #2's Name: *

Is he/she a full time or part time student? *

Full time

Part Time

Full time students must provide the following:

Student Status Verification Form (Available at THA)
Financial Aid Award Letter
Tuition Detail

Part time students must provide the following:

Student Status Verification Form (Available at THA)

Additional Student's Name: *

Is he/she a full time or part time student? *

Full time

Part Time

Full time students must provide the following:

Student Status Verification Form (Available at THA)
Financial Aid Award Letter
Tuition Detail

Part time students must provide the following:

Student Status Verification Form (Available at THA)

Income Increase

Whose Income Changed: *

Total Amount of Increase: *

Frequency *

What is the Income Source? (Check all that apply.): *

Please Provide Your Employer Information:

Name of Company: *

Company Phone #: *

Address: *

City: *

State: *

Zip code: *

You Must Submit the following:

Award letter for proof of child support

Attach Here:

You Must Submit the Following:

Award letter for proof of DSHS increase

Attach Here:

You Must Submit the Following:

If available, please include a paycheck stub or letter from your employer.

Attach Here:

You Must Submit the Following:

Award letter for proof of pension increase

Attach Here:

You Must Submit the Following:

Award letter for proof of SSI/SS increase

Attach Here:

You Must Submit the Following:

Any documents pertaining to the "other" increase

Attach Here:

Any additional details regarding this change:

Income Decrease

Whose Income Changed: *

Total Amount of Decrease: *

Frequency *

What income source is changing?: *

Please Provide Your Employer Information:

Name of Company: *

Company Phone #: *

Address: *

City: *

State: *

Zip code: *

You Must Submit the following:

Award letter for proof of child support

Attach Here:

You Must Submit the Following:

A document from DSHS that verifies the decrease or end of DSHS assistance

Attach Here:

You Must Submit the Following:

A letter from your employer on company letterhead with the company's contact information if a decrease is given, and an unemployment determination letter if you lost your job

Attach Here:

You Must Submit the Following:

Award letter for proof of pension decrease

Attach Here:

You Must Submit the Following:

Award letter for proof of SSI/SS decrease

Attach Here:

You Must Submit the Following:

Any documents pertaining to the "other" decrease

Attach Here:

Any additional details regarding this change: *

Add Someone to the Household

How many people are you adding to the household? *

Who is being added?

Addition #1:

First Name: *

Last Name: *

Age: *

Date of Birth * +

Relation to Head of Household: *

Reason for Adding: *

Adoption/Custody

Birth

Marriage

Other Other

Is this person bringing new income to the household?: *

Amount: *

Frequency *

What is the Income Source? (Check all that apply.):

Please Provide The Employer Information:

Name of Company:

Company Phone #:

Address:

City:

State:

Zip code:

Proof of Income Attachment:

Signature of person you are adding to the household
(if he/she is over the age of 16):

Date: +

Addition #2:

First Name: *

Last Name: *

Age: *

Date of Birth * +

Relation to Head of Household: *

Reason for Adding: *

Adoption/Custody

Birth

Marriage

Other Other

Is this person bringing new income to the household?: *

Amount: *

Frequency *

What is the Income Source? (Check all that apply.):

Please Provide The Employer Information:

Name of Company:

Company Phone #:

Address:

City:

State:

Zip code:

Proof of Income Attachment:

Signature of person you are adding to the household
(if he/she is over the age of 16):

Date: +

Addition #3:

First Name: *

Last Name: *

Age: *

Date of Birth * +

Relation to Head of Household: *

Reason for Adding: *

Is this person bringing new income to the household?: *

Amount: *

Frequency *

What is the Income Source? (Check all that apply.):

Please Provide The Employer Information:

Name of Company:

Company Phone #:

Address:

City:

State:

Zip code:

Proof of Income Attachment:

Signature of person you are adding to the household
(if he/she is over the age of 16):

Date: +

Any additional details regarding this change: *

YOU MUST SUBMIT THE FOLLOWING:

Documentation requirements to have the change processed:

All

Letter from your landlord acknowledging the addition. Must have a date and signature

Eligible Non-Citizen

Documentation of citizenship

Custody

(client provides ONE of the following)

Parenting Plan
CPS Order documentation
Court Order documentation

-OR-

(client provides TWO of the following)

DSHS award letter (TANF or food stamps on behalf of the child joining the household)
School enrollment document
Medical provider’s note
Signed and notarized statement from biological parent
Signed and notarized statement from the client stating child resides in their care and custody full time
Juvenile court record showing the client as parent/guardian of the child

Members 0 to 15 years old

Birth certificate
Social Security card
Verification of Income (If applicable)

Members 16 to 17 years old

Birth certificate
Social Security card
Third party release form
Verification of Income (If applicable)

Members over 18 years old

State ID or driver's license
Social Security card
Third party release form
Verification of Income (If applicable)

Caregiver

Reasonable accommodation approval
State ID or driver's license
Social Security card
Third party release form

Foster Child

Verification of foster parent status from the foster agency

Third Party Release Form (M-1)

I hereby authorize Tacoma Housing Authority (THA) and the U.S. Department of Housing and Urban Development (HUD) to obtain the information listed below for the purpose of determining my eligibility to receive and continue receiving housing assistance. THA may use this release to make inquiries or secure information from any source whatsoever, including a person, business, or organization that has, or may have, any information listed below. If THA makes any negative determination(s) based upon the information obtained, I will have an opportunity to contest such determinations. If I participate in the Project-based or Mod Rehab program, I also authorize THA and the owner and/or manager of the building in which I reside to share with each other any information needed to verify my continued eligibility and suitability for subsidized housing. This consent expires 48 months after it is signed.

Information necessary to authenticate preference claims;
Rental history records and references, including but not limited to, information about the ability to pay rent, the ability to abide by the rules of the lease, take care of rental property, and get along well with neighbors;
Non-residential references from individuals with whom a professional relationship has been established, and references from neighbors, community, and relatives;
References from employers, including wage and salary information, and job performance;
Criminal history, including fingerprint submission where necessary to effect positive identification;
Information on payment history and balances owed to utility companies including but not limited to TPU, Puget Power, WNG;
Credit reports;
Services provided by individuals or agencies which are relevant to the ability to pay rent, take care of rental property, and get along well with neighbors and community;
(HUD only) U.S. Social Security Administration and U.S. Internal Revenue Service;
Income and asset information from any source, including State Wage Information Collection Agencies, for all family members;
Immigration status, citizenship status, and legal identity verification;
School registration for minor children, and for family members over the age of 18 where required to establish program eligibility;
Registration in educational or vocational training programs including information about participation/completion of such programs;
Verification of disability or handicap and shelter plus programs, if necessary for program eligibility (not including details of actual disability or handicap);
Verification of need for reasonable accommodation, if requested;
Credit reports and/or tenant screening reports from private screening contractors;
Outstanding debts to other housing agencies.

Is there anyone else in the home that is over 16 years of age? *

Yes

No

Number of people, excluding yourself, that are over the age of 16. *

Head of Household: I declare under penalty of perjury that the information provided in this petition is true and correct.

Signature of Head of
Household: *

Date: * +

Preparer and/or Tenant: I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the head of household.

Signature of Preparer: *

Date: * +

Additional signature(s) required for occupants that are 16 years or older:

Signature: *

Date: * +

Signature: *

Date: * +

Signature: *

Date: * 🛈 +

Signature: *

Date: * +

Signature: *

Date: * +

Signature: *

Date: * +

Supplement to Application for Federally Assisted Housing

OMB Control#2502-0581, Expires 11/30/2015

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Check this box if you choose not to provide the contact information.

Applicant Name
(Last,First):

Mailing Address:

City

State:

Zip Code:

Phone:

Cell Phone Number:

Email:

Name of Additional Contact
Person or Organization:

Address:

City

State:

Zip Code:

Phone:

Cell Phone Number:

Email:

Relationship to Applicant:

Reason for Contact:

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Head of Household: I declare under penalty of perjury that the information provided in this petition is true and correct.

Signature of Head of
Household:

Date: +

Preparer and/or Tenant: I declare under penalty of perjury that the information provided in this petition is true and correct, and that I have been authorized to file this petition on behalf of the head of household.

Signature of Preparer:

Date: +

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.

Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

*

I understand the following:

YOU MUST TURN IN APPLICABLE DOCUMENTATION TO THE THA WITHIN 10 DAYS OF SUBMITTING THIS FORM, OR THE CHANGES WILL NOT BE PROCESSED AND THE PERSON CANNOT MOVE IN. YOU CAN ATTACH THE APPROPRIATE DOCUMENTS HERE:

Attach Here:

**Notice** Only 1 file can be uploaded per upload box. For additional uploads, please use the additional upload boxes.

OR DO THE FOLLOWING:

-Email to changes@tacomahousing.org

-Fax to (253) 207-4454

-Mail to 902 S. L Street, Tacoma, WA 98405

-Bring in the documents, during business hours, to 902 S. L Street, Tacoma, WA 98405

*

I understand the following:

The increase will not be processed until the supporting documents are turned in. They can be attached to this document, or you have the following options:

-Email to changes@tacomahousing.org

-Fax to (253) 207-4454

-Mail to 902 S. L Street, Tacoma, WA 98405

-Bring in the documents, during business hours, to 902 S. L Street, Tacoma, WA 98405

Remove Someone to the Household

Who are You Removing?:

Name of Person Being Removed: *

Additional Person Being Removed:

Have You Notified the Landlord?: *

PROCESS CANNOT BE COMPLETED UNTIL YOU NOTIFY YOUR LANDLORD!

Any additional details regarding this change: *

Do You Owe Money to a Housing Authority and/or Landlord?: *

When Would You Like to Port?: * +

Name of the Housing Authority You Would Like to Port to: *

Do You Know the Address of the Unit You Would Like to Port to?: *

Address:

City:

State

Zip:

***DUE TO YOU ANSWERED "I DO NOT MEET ANY OF THESE REQUIREMENTS ", YOU DO NOT QUALIFY TO PORT OUT.***

***DUE TO YOU OWE MONEY TO THA AND/OR A LANDLORD YOU DO NOT QUALIFY TO PORT OUT.***

Additional details regarding this change: *

*

BY SUBMITTING THIS DOCUMENT, I ACKNOWLEDGE THAT THIS PERSON IS NO LONGER IN THE HOUSEHOLD. IF THA DISCOVERS THIS PERSON IS STILL IN THE HOUSEHOLD, ASSISTANCE COULD BE TERMINATED.

*

I understand the following:

I understand that knowingly supplying false, incomplete, or inaccurate information is punishable under federal or state criminal law. I will also be required to repay assistance overpaid on my behalf, and may be terminated from the program. I certify by submitting this form that all of the information I provide to THA is true and accurate.