Arlington Dhs Housing Choice Voucher Program Family Report Of Loss Of Household Income
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1Arlington DHS Housing Choice Voucher Program
rd
2100 Washington Blvd. 3
floor
Arlington, VA 22204
Tel 703.228.1450 FAX 703.228.1042
FAMILY REPORT OF LOSS OF HOUSEHOLD INCOME
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Head of Household ____________________________________________Telephone ______________
Address: ___________________________________________________________________________
___________________________________________________________________________________
Social Security Number: __________________________ Email: ______________________________
1.
LOSS OF INCOME: You must provide proof of lost income. (Examples include letter from agency,
or employer.)
Name of family member
Type of income lost
Amount of income lost
Date income
who lost income
(wages, TANF, etc.)
(weekly, monthly?)
stopped
2. INCREASE IN ALLOWABLE EXPENSES: You must provide proof of insured expenses
(Examples include letter from provider, current receipts).
Type of expense
Amount of Increase per month
Date increase began
Date expense stopped
Childcare expenses
Medical expenses
Disability
assistance expense
Other Expense
3. BELOW IS AN EXAMPLE OF DOCUMENTS YOU MUST SUBMIT AS PROOF OF THE LOSS
OF INCOME OR INCREASE IN ALLOWABLE EXPENSES THAT YOU ARE REPORTING.
Copies of recent pay stubs, letter from employer, or documentation of earnings and expenses.
New or increased childcare expense including the name, address, telephone of the care provider.
New or increased medical expenses with the name, address, telephone of the medical source of the change.
New or increased disability assistance expense including the name, address, telephone of the care attendant
for the disabled household member and the name of the disabled member.
Notice of loss of employment from the employer.
Other changes: (specify type of change in income) _______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Warning: Section 1001 of Title 18 of the U.S. Code states that a person is guilty of a felony for knowingly and
willingly making false or fraudulent statements or misrepresentations to any Department or Agency of the
U.S. as to any matter within its jurisdiction. I certify under penalty of perjury that I have supplied accurate
and complete information about my household. I understand that reporting of false or incomplete
information is fraud and may result in denial or termination of rental housing assistance. I realize that as
Head of Household I am responsible for insuring that the information is complete and accurate for all
household members.
__________________________________
__________________________
Signature of Head of Household
Date
ACROBAT OCC-06 Family LOSS of Income OCT 2013
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