Duplicate Housing Expense Form
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(Check One)
DUPLICATE HOUSING EXPENSE ASSISTANCE – Policy X 20 06
If you qualify for duplicate housing assistance according to current denominational policy (on
back), complete the following information:
1.
Your Name: _____________________________________________________________
( please print)
2.
Location of unsold residence: _______________________________________________
Address
_______________________________________________
City
State
Zip
3.
Date duplicate housing expense began: ________________________________________
4.
Duplicate housing allowance is being requested for these dates:
From____________________________ through__________________________ (month)
5.
Do you currently have your house up for sale?
Yes
No
6.
What is the asking price?
$______________________
7.
What is the appraised value?
$______________________
8.
Have you obtained an independent appraisal?
Yes
No
(required after 3 months/see policy on back)
9.
Is your house rented or leased?
Yes
No
10.
Rental income for this period.
$______________________
11.
Name of former employer: __________________________________________________
12.
Cost-of-living category with former employer:
A
B
C
D
E
(Check One)
13.
Monthly expenses on unsold residence:
0.00
Mortgage Principle/Interest $_______________________
0.00
Property Taxes
$_______________________
0.00
Utilities
$_______________________
0.00
Insurance
$_______________________
0.00
Total
$_______________________
This assistance, if needed, must be requested each month. You will receive reimbursement
through your payroll check.
Employee Signature: ___________________________________________ Date___________________
Ohio Conference of SDA – P O Box 1230, Mt. Vernon, OH 43050 – Phone: 740-397-4665
Rev 6-06
H:Treasury/Duplicate Housing Expense Assistance
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