Request For Voucher Extension Form
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1Public Housing and Community Development
Miami‐Dade Housing Choice Voucher Program
P.O. Box 521750
Miami, FL 33152‐1750
TTD/TTY Florida Relay Service
Carlos A. Gimenez, Mayor
1‐800‐955‐8771 or Dial 771
Customer Service Number: 305‐403‐3222/ Fax: 786‐358‐5893
Si necesita ayuda con este formulario, llame al 305‐403‐3222
Si w bezwen asistans ak fòm sa a, tanpri rele 305‐403‐3222
REQUEST FOR VOUCHER EXTENSION
A family may request a thirty (30) day extension(s) to the initial sixty (60) day term of an issued Voucher. All requests for extensions
should be received at least one week prior to the expiration date of the voucher. The request must be submitted in writing to our
P.O. Box, Fax or delivered to our office to the attention of Voucher Extension Request. Extensions are permissible at the discretion of
MDHCVP primarily two reasons, as follows:
EXTENUATING CIRCUMSTANCE
:
1.
Extenuating circumstances such as hospitalization of a family member or a family
emergency over an extended period of time that has affected the family’s ability to find a unit within the initial (60) day
term.
REASONABLE ACCOMODATION FOR AN ACCESSIBLE UNIT
2.
:
As a reasonable accommodation for a family
member with disabilities or for a family member with disabilities to find an accessible unit.
Entity ID:
HOH Name:
Telephone Number:
Email Address:
Please select below the reason for your request for a voucher extension.
EXTENUATING CIRCUMSTANCE
Briefly explain nature of circumstance: _______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
REASONABLE ACCOMODATION FOR AN ACCESSIBLE UNIT
Briefly detail accessibility requirements: ______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signature: ________________________________________
Date: _____________________________
FOR MDHCVP USE ONLY
Original Issue Date: _______________________
Original Expiration Date: _____________________________
Is this the first Extension Request?
Yes
No
If No selected, provide the first voucher extension issue date: _______________ Expiration Date: ___________________
New Issue Date: ____________________________
New Expiration Date: ____________________________
Check below if applicable:
FINAL VOUCHER EXTENSION
Approved By: ________________________________________
Date: __________________________________
MDC‐0054 Request for Voucher Extension
Rev. 11/2014
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