CENTRAL IOWA REGIONAL HOUSING AUTHORITY (CIRHA)
CHANGE FORM Please include ALL household information and income, NOT just what has changed. **FAILURE TO COMPLETE THE ENTIRE APPLICATION OR PROVIDE READABLE INFORMATION WILL RESULT IN YOUR APPLICATION NOT BEING PROCESSED – PLEASE PRINT!!!***
Head of Household								Contact Number
Full Address including City, State, Zip								Work Phone
CHECK : Income Change(s) _________ Household Change(s) _________ Other Change(s) _________
Explain reason(s) for change(s):
Part 1 – Household Composition
Starting with the Head of Household (HOH), please supply the following information for ALL adults and children that will live in the household. List all adults first, then children, and include each person’s relationship to the HOH.
	First Name	M.I.	Last Name	Date of Birth	Age	Sex	Relationship to HOH		Social Security #
1							Head
2
3
4
5
6
7
8
The Head of Household or Spouse is (Please Check ANY That Apply): _____ Elderly (62 or Older) _____ Disabled

Part 2 – Income Information
Circle either Yes or No for each category. If Yes, then complete all information. Provide accurate CURRENT and ANTICIPATED income for ALL family members.
		Income Type:	Address:	Family Member	Gross Mthly Income
Yes	No	Social Security
Yes	No	SSI
Yes	No	Other Disability/Worker’s Comp
Yes	No	Pension
Yes	No	FIP/TANF
Yes	No	Child Support
Yes	No	Alimony
Yes	No	Wages/Salary Source:
		Name of employer:
		Name of employer:
		Name of employer:
		Name of employer:
Yes	No	Unemployment
Yes	No	Military Pay
Yes	No	Net Business/Farm Income
Yes	No	Rental Income
Yes	No	Retirement Plans
Yes	No	OTHER:
IS ANY MEMBER OF YOUR HOUSEHOLD:
Yes	No	18 YEARS OF AGE OR OLDER ATTENDING HIGH SCHOOL FULL TIME? If yes, Who:____________________________ Where:______________________________
Yes	No	18 YEARS OF AGE OR OLDER ATTENDING COLLEGE FULL TIME? If yes, Who:____________________________ Where:______________________________
Please complete both sides of form

Part 3 – Asset Information
		Asset Type:	Family Member	Amount	Bank Name and Address
Yes	No	Cash
Yes	No	Checking Account
Yes	No	Bank name:
Yes	No	Bank name:
Yes	No	Savings Account
Yes	No	Bank name:
Yes	No	Bank name:
Yes	No	Life Insurance/401K/IRA
Yes	No	C.D./Bonds/Stocks
HAS ANY MEMBER OF YOUR HOUSEHOLD:
Yes	No	Sold or given away real property or other assets (including cash) in the past two years?

Part 4 – Childcare Expenses Do you pay childcare/disability assistance expense out of your pocket while you work, got to school or look for work? Yes or No
Child Care Provider	Family Member	Amount You Pay	Address

Part 5 – Medical Expenses FOR ELDERLY AND DISABLED FAMILIES ONLY (other applicants skip to the signature section)
		Type of Expense:	Family Member	Amount	Name and Address
Yes	No	Medicare Premiums
Yes	No	Medical Costs
Yes	No	Prescription Drugs
Yes	No	Supplemental Health Insurance
Yes	No	Disabled/Dependant Care Costs
Yes	No	Other
List the monthly amount of medical expenses you paid without assistance: $______________

PRIVACY ACT OF 1974 (PL 93 - 579) STATEMENT: Authority: Section 7(d) Department of Housing and Urban Development (HUD) Act (42 USC 3535(d)): Section 5(b) of the U.S. Housing Act of 1937 (42USC 1437 f). Purpose: The information requested in this form is to be used by HUD to determine maximum income for eligibility, recommended unit size and the amount of the individual contribution by the applicant. Use: This information may not be disclosed outside HUD, except as required or permitted by law. DISCLOSURE OF THIS INFORMATION IS MANDATORY.

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. as to any matter within its jurisdiction.

Signature Section
By signing below, I/we certify that the information given to the CIRHA on household composition, income, assets, and allowances is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are grounds for the denial/termination of rental assistance and are punishable under Federal law. In accordance with the Privacy Act of 1974, after verification by the CIRHA, information will be submitted to HUD on HUD Form-50058.
Head of Household Signature	Date
Spouse/Other Family Member over age 18 Signature	Date
Spouse/Other Family Member over age 18 Signature	Date

Central Iowa Regional Housing Authority

1201 SE Gateway Drive, Grimes, Iowa 50111

(515) 986-1882

(515) 986-1883 fax

www.cirhahome.org