Voucher Extension Request Form
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4HOUSING AUTHORITY OF MARICOPA COUNTY
Housing Choice Voucher
CHANGE REPORT FORM
Head of Household:
Soc Sec #:
Email Address: ______________________________________________________________________
Mailing Address:
Phone #:
Street Address
City
Zip
MARK ALL THAT APPLY – USE SEPARATE FORM IF NEEDED.
EMPLOYMENT CHANGE
INCREASE
DECREASE
(MUST ATTACH VERIFICATION: 30 days of current and consecutive pay stubs, or letter from employer stating pay rate and
average hours you will work)
Member with income change:
Effective date:
Name of Employer:
Address:
Phone:
FAX:
Start date:
Hourly Wage: $
Hours per Week:
Reason for Decrease: Termination
Reduced hours: Old # of hours?
New # of hours?
Other reason:
Check one: INCREASE
DECREASE
OTHER INCOME CHANGE
Member?:
(MUST ATTACH: SS/SSI/TANF/Food Stamp Award letters, Child Support statements, Print-outs, etc.)
Social Security/SSI
Amount: $
Effective: ___________________
FOOD STAMPS
Amount: $__________
Effective: __________________
TANF
Case #:
Amount:$
Effective:
Child Support
State: _____ Case#:
Amount: $
Effective:
Other (explain):
Amount: $
Effective:
HOUSEHOLD COMPOSITION CHANGE
ADD
REMOVE
To ADD: MUST ATTACH: Birth Certificate, Social Security Card, Written Permission from your Landlord. For Adults: must
also attach Picture ID, Proof of Income and Signed Release of Information Form.
Name:
Relation:
DOB:
SS#
CHILD CARE
Check one: New
Increase
Decrease
No longer Have Child Care
Child Care Provider Name:
Full Address:
Phone Number:
Amount you pay per week: $
I certify that the information given to the Housing Authority of Maricopa County is accurate and complete to the best of my knowledge
and belief. I understand that false statements or information is punishable under Federal law. I also understand that false statements
or information is grounds for termination of housing assistance.
PRINT NAME
SIGNATURE
DATE
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any department or agency of the U.S. or to any
matter within its jurisdiction.
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