Change Reporting Form printable pdf download

Greene Metropolitan Housing Authority

538 N. Detroit Street, Xenia, OH 45385

Xenia: 937.376.2908 Fairborn: 937.429.7736 Section 8 Fax: 937.376.2487 TDD: 937.374.1607

website: gmha.net

GMHA CHANGE REPORTING FORM

Failure to supply complete and accurate information will result in a delay of your assistance and return of this form to you. Please submit

all verifications to document the changes you are reporting on this form.

Head of Household: ______________________________________________________________ SS#_________________________

Name of Household member with change: ____________________________________________ SS#_________________________

Current Address ____________________________________________ City ___________________ State ______ Zip ___________

Telephone ________________ Fax Number ___________________ Email Address:________________________________________

Old Address _______________________________________________ City ___________________ State ______ Zip ___________

EMPLOYMENT INCOME:

Begin Date________________

End Date: __________________

Employer___________________________________________________________________________________________________

Address __________________________________________________ City ___________________ State ______ Zip ___________

Telephone ________________ Fax Number ___________________ Email ______________________________________________

OTHER INCOME CHANGES:

Begin Date: __________________OR End Date: ___________________

___SSI

___Social Security

___Child Support

___OWF/FS/DA/Medicaid

___Unemployment

____Other Change (Please list contact information for this source) _____________________________________________________

EXPENSES:

Begin Date: __________________ OR

End Date: ______________________________

___Medical Expenses

___Prescription Expenses

____ Child Care Expenses

Please provide name, address, phone and fax number for this expense on the lines provided below:

___________________________________________________________________________________________________________

Please also, provide completed Verification of Child Care form and 12 month printout of ALL Medical Expenses

Deletions to the Household:

_____________________________________

(You must also attach a completed decrease in family composition).

Request to Add

:(You must also attach authorization for additional person(s)

___________________________________________________

form)

OTHER COMMUNICATON: ____________________________________________________________________________________

___________________________________________________________________________________________________________

Tenant Signature:_________________________________________________Date:___________Tenant Telephone #:____________

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