Change Of Circumstance - The Housing Authority Of Snohomish County
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4The Housing Authority of Snohomish County
th
12711 4
Ave. W, Everett, WA 98204
Phone:425-290-8499; Fax: 425-290-5618
Change of Circumstance
Head of Household Name:
Last 4 of Social Security Number:
Phone Number:
Email:
Instructions: Complete only the sections that apply to your change; attach supporting documentation.
Type of Change Being Reported: (Check all that apply)
Increase in Household Income
Remove a Household Member
Decrease in Household Income
Other:
Add a Household Member (You must complete an Add a Member or Add a Minor packet)
Employment: (Attach paystubs or letter from employer)
New Employment
Change in Pay
Employment Ended
Household Member:
Household Member:
Employer Name:
Employer Name:
Employer Phone:
Employer Phone:
Employer Fax:
Employer Fax:
Employer Address:
Employer Address:
Effective Date of Change:
Stop Date:
Hourly rate of pay: $
Hours per week:
Other Income: (Check all that apply)
Trust/Retirement
Child Support
Pension or Annuity
Disbursements
VA Benefits
Gifts or Contributions
DSHS Benefits
Social Security or SSI
Unemployment
L&I Benefits
Short or Long-Term Disability
Other:
Household Member:
Household Member:
Describe Change:
Describe Change:
Amount: $
Per:
Week
Month
Amount: $
Per:
Week
Month
Start Date:
Stop Date:
Start Date:
Stop Date:
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