Income Change Request Form printable pdf download

INCOME CHANGE REQUEST FORM

In order to request an interim adjustment to your rent portion, you must complete this attached form

and return it with the required documentation as proof of the change within ten (10) business days of

when the income change happens. Failure to report an increase in income may require you to repay

money to MPHA.

The change will be effective on the first of the month following a full month waiting period in order to

gather necessary information and to provide a 30-day notice of your new rent portion. For example:

•

If you report a change in January, January is your reporting month

•

February then is the waiting month, allowing us time to gather replacement income information

and provide both you and the property owner a 30-day notice of the change

•

The change will be effective March 1

Under MPHA’s Rent Reform Initiative, household members who are employed do not need to report

increases in earned income. Household members who are employed may increase their earnings or get

an additional job without reporting the income change until the time of their annual re-examination.

However, increases in income that are not from employment and any new employment for any

previously unemployed household member must be reported.

Additionally, under the Rent Reform Initiative, requests for an interim to decrease your income are

limited to one per year (only one decrease in income is allowed between annual recertifications).

Families can apply for a hardship waiver of this limitation under certain circumstances.

The following is a list of the required documents needed to process your interim, depending on the type

of income change occurring. Failure to provide this documentation will result in a delay of the interim

rent adjustment. Please attach the appropriate documentation to this form, according to what type of

income change you are reporting. Please retain a copy of the fax confirmation, email transmittal, or

date stamped receipt of your submitted request for your records.

Type of Income Change

Documentation Required

Letter on employer’s letterhead stating rate of pay, hours worked per

New job

pay period, and hire date

Letter on employer’s letterhead stating stop work date

Lost job

Unemployment award letter or unemployment denial letter

Change in GA/MFIP

Benefit statement

Change in Child Support

Benefit statement

Payment history from county (if available)

Social Security

Award letter or benefit statement

1001 WASHINGTON AVENUE NORTH MINNEAPOLIS, MN 55401-1043 PHONE: (612) 342-1480 FAX: (612) 335-4427

EQUAL HOUSING OPPORTUNITY – EQUAL EMPLOYMENT OPPORTUNITY

Income Change Request Form