Preliminary Income Change Form

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Files can be PDF, JPG, JPEG format.","name":"file-upload-for-pay-stubs","subtype":"file","multiple":true,"className":"d-block"},{"type":"text","required":true,"label":"Resident Name:","name":"resident-name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Resident Phone:","name":"Resident-phone","className":"col-md-6"},{"type":"text","required":true,"label":"Street Address","name":"street-address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"City","name":"city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"State","name":"State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of 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Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC","selected":true},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code","name":"zip-code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Name of Employer/Staffing Company","name":"employer-or-staffing-company","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Employer/Staffing Company Phone","name":"employer-phone","className":"col-md-6"},{"type":"text","label":"Employer Address","name":"employer-address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Employer Address City","name":"employer-address-city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"Employer State","name":"employer-state","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC","selected":true},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Employer Zip","name":"Employer-Zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Rate of Pay","name":"rate-of-pay","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Total Number of Hours Worked Each Week.","name":"total-hours-worked-weekly","className":"col-md-6","subtype":"text"},{"type":"select","required":true,"label":"I am Paid:","name":"payment-frequency","className":"col-lg-4","values":[{"label":"-Select One-","value":"no selection","selected":true},{"label":"Weekly","value":"weekly"},{"label":"Bi-Weekly","value":"bi-weekly"},{"label":"Semi-Monthly","value":"semi-monthly"},{"label":"Monthly","value":"monthly"}]},{"type":"date","required":true,"label":"Date Started","name":"date-started","className":"col-lg-4"},{"type":"date","label":"Date Stopped","name":"date-stopped","className":"col-lg-4"},{"type":"text","label":"Additional Source(s) of Income","name":"additional-sources-of-income","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Additional Income Amount","name":"amount-of-additional-income","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Date Began Receiving Additional Income","name":"date-began-receiving-additional-income","className":"col-lg-4"},{"type":"select","label":"Do you pay for Child Care?","name":"do-you-pay-for-child-care","className":"col-md-6 col-lg-3","values":[{"label":"-Select One-","value":"no selection","selected":true},{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"text","label":"If yes, list name of provider","name":"name-of-child-care-provider-if-answered-yes","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"Payment Frequency","name":"child-care-payment-frequency","className":"col-md-6 col-lg-3","values":[{"label":"-Select One-","value":"no selection","selected":true},{"label":"Weekly","value":"weekly"},{"label":"Bi-Weekly","value":"bi-weekly"},{"label":"Semi-Monthly","value":"semi-monthly"},{"label":"Monthly","value":"monthly"}]},{"type":"text","label":"Amount Paid","placeholder":"$","name":"amount-paid","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Child Care Provider Address","name":"child-care-address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Child Care Provider City","name":"child-care-city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"Child Care State","name":"Child-Care-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC","selected":true},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Child Care Provider Zip","name":"child-care-zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"select","label":"1a. Has anyone moved into or out of your home?","name":"has-anyone-moved-in-or-out-of-your-home","className":"col-md-6","values":[{"label":"-Select One-","value":"no selection"},{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"text","label":"1b. If anyone has moved in or out, who?","name":"if-yes-who","className":"col-md-6","subtype":"text"},{"type":"checkbox-group","label":"2. Does anyone in your household receive any of the following? Mark all that apply","inline":true,"name":"additional-assistance-sources","className":"d-block","values":[{"label":"AFDC/FI","value":"afdc/fi"},{"label":"Public Assistance (Food Stamps)","value":"public assistance/food stamps"},{"label":"Social Security","value":"social security"},{"label":"Pension","value":"pension"},{"label":"Disability Payments","value":"disability payments"}]},{"type":"select","required":true,"label":"3. Does anyone outside of your household pay any of your bills, or give you money? (If YES, complete a Self Certification form. Contact our office for the Self-Certification form or provide a notarized statement)","name":"does-anyone-outside-of-your-household-help-financially","className":"d-block","values":[{"label":"-Select One-","value":"no selection"},{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"select","required":true,"label":"4. Does anyone in your household receive any type of income or money not mentioned above?","name":"anyone-in-the-household-receive-any-income-or-money-not-mentioned","className":"d-block","values":[{"label":"-Select One-","value":"no selection","selected":true},{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"text","label":"Comments: Explain any 'YES' answers","name":"explain-any-yes-answers","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I certify that answers I have given are true and accurate to the best of my knowledge, and have no objection to inquiries being made to verify any statement herein.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I UNDERSTAND THAT AN INTERIM ADJUSTMENT WILL BE PROCESSED ONCE THE HOUSING AUTHORITY HAS RECEIVED THIRD PARTY VERIFICATION IF NECESSARY.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Disclaimer: By typing your name, you are signing this document.","className":"d-block"},{"type":"text","required":true,"label":"Participant's Signature","name":"Participants-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature","name":"date-of-signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"WARNING! Title 18, Section 1001 of the U.S. Code, states that any person who knowingly and willingly make false or fraudulent statement to any Department or Agency of the U.S. or the Department of Housing and Urban Development is guilty of a felony.","className":"d-block"}]

Preliminary Income Change Form

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