Verbal Verification of Income

Tenant Name

Unit Number

Phone Number

The above tenant has reported the following changes in income today:

New Employment

Terminated Employment

Change in Source of Income

DHHS

Place of Employment

Address of Employer

Employer Phone Number

Employer Fax Number

Current Wage

Number of Hours Per Week

DHHS Case Worker

Other Comments

Please attach any documents (check stub, award letters, etc)

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The above verbal verification is being used as an estimate of income until such time the income verifications have been signed and returned to our office. If the verifications return different than indicated, appropriate adjustments will be made.

I understand that all income changes must be reported within ten (10) days, for example: ten (10) days from hire date (not pay date), ten (10) days from an award of social security, ten (10) days an your award of unemployment or any other income. In addition to submitting this form I understand that I must go into the office to sign necessary verifications and/or submit pay stubs, award notices and any other documentation necessary to complete my rent calculation.

Earned Income Disallowance Worksheet

Have you been employed in the last 12 months?

Yes

If you answered yes to #1, did you earn less than $4,825.00 during the last 12 months?

Yes

Within the last six months, have you received cash assistance or benefits through TANF?

Yes

Aside from monthly income maintenance, did you receive TANF assistance, benefits, or services worth at least $500 over the past six months?

Yes

Did you have increased earnings during participation in any economic self-sufficiency or job training programs?

Yes

A disallowance will be applied to any qualified family whose annual income increases due to one of the following reasons:

1. Employment of a family member who was previously unemployed for one or more years prior to employment.

2. Increased earnings by a family member during participation in any economic self-sufficiency or other job training program.

3. New employment or increased earnings of a family member during or within 6 months after receiving assistance, benefits or services under any state program for temporary assistance (TANF, Welfare-to-Work).

▪ TANF assistance may consist of any amount of monthly income maintenance,

▪ At least $500 in such TANF benefits and services as one-time payments, wage subsidies and transportation assistance.

▪ The $500 minimum dollar requirement applies only to one-time benefits, wage subsidies, and transportation.

The Earned Income Disallowance will begin on the first day of the month following the effective date of employment or the first day of the month following an increase in income.

The full amount of increase is excluded, and the exclusion extends for a total of 12 cumulative months.

Second 12-Month Exclusion and Phase-In

Fifty percent of any increase is excluded and begins after the qualified family has received 12 cumulative months of full (100%) exclusion. The 50% exclusion is applied for a maximum of 12 cumulative months.

Lifetime Maximum Four Year Disallowance

No exclusion may be given after the 24-month period, regardless of whether the family has received the full exclusion for a total of 12 months or the phase-in exclusion for a total of 12 months.

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First Name

Last Name

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I certify that the above information is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years or lose the subsidy I receive and have my rent increased, if I furnish false or incomplete information.