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Change in Income Form

You are here: Home1 / Change in Income Form

Change in Income Form

  • Complete once for each change in income. If you quit a job, start a different job, get a TANF decrease, and another member of your household has a change in hours at their job, you would complete and submit 4 separate changes.
  • Select all that apply
  • List days of the week and times
  • Changes

  • You selected an employment change. Please fill out the rest of the form.

  • You have selected employment start. Please fill out the rest of the form

  • MM slash DD slash YYYY
  • Enter future date if you have not been paid yet
  • ex: weekly, every 2 weeks, monthly, etc
  • If not yet paid, enter "0"
  • bonuses, tips, overtime, etc
  • Please explain additional pay
  • I understand I will need to submit pay stub(s), offer letter from employer, or employment verification form. Due to COVID-19 we encourage digital submissions. You can email a photo to your case worker or ask your employer to send documents directly to your case worker. You may also submit documents (or pictures of documents) with this form. If needed, you can drop forms off at the main office. For Employment verification form, copy this link to print or send to your employer: https://harrisonburgrha.com/wp-content/uploads/2019/05/Household_Employment-Verification.pdf
  • You have selected employment end. Please fill out the rest of the form.

  • MM slash DD slash YYYY
  • past or expected
    MM slash DD slash YYYY
  • if still awaiting final paycheck leave blank
  • You must report any unemployment income received. Failure to do so is a program violation.
  • Please add any relevant details about your plans to receive unemployment such as dates, amount, etc.
  • I understand I will need to submit final pay stub, confirmation of last day worked from employer, or employment verification form. Due to COVID-19 we encourage digital submissions. You can email a photo to your case worker or ask your employer to send documents directly to your case worker. You may also submit documents (or pictures of documents) with this form. If needed, you can drop forms off at the main office. For Employment verification form, copy this link to print or send to your employer: https://harrisonburgrha.com/wp-content/uploads/2019/05/Household_Employment-Verification.pdf
  • You have selected employment change in hours or pay. Please fill out the rest of the form.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • bonuses, tips, overtime, etc
  • I understand I will need to submit pay stub(s), offer letter from employer, or employment verification form. Due to COVID-19 we encourage digital submissions. You can email a photo to your case worker or ask your employer to send documents directly to your case worker. You may also submit documents (or pictures of documents) with this form. If needed, you can drop forms off at the main office. For Employment verification form, copy this link to print or send to your employer: https://harrisonburgrha.com/wp-content/uploads/2019/05/Household_Employment-Verification.pdf
  • You have selected employment temporary leave. Please fill out the rest of the form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • If still waiting for last check leave blank
  • You must report any unemployment income received. Failure to do so is a program violation.
  • Please list date range or "I don't know"
  • We will use this for a future certification
  • You will be required to submit updates of any changes following this one. If not complete on time, you may have to repay.
  • You have selected a non-employment change. Please fill out the rest of the form.

  • If adult receiving SS/SSI for a child, fill in the child's name.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • You will need to submit Virginia DCSE Payment History
  • You will need to submit DSS Notice of Action on Benefits
  • You will need to submit SSA Notice of Benefits
  • You will need to submit Determination Statement (State Employment Commission)
  • You will need to submit the benefit/award letter or printout
  • You will need to submit court order or other benefit/award statement
  • You will need to submit documentation from the provider containing contact information, name and amount and frequency of payments
  • You will need to submit prior year tax information or documentation of gross income and business expenses
  • You will need to submit Gifts or Contributions Certification form (Link pending - in the document center)
  • You will need to submit a printout of grant award, and attach a printout showing all expenses such as tuition and fees
  • Final Check

    Please check your answers above to make sure information is accurate.
  • This includes your social security number, bank account number, passport info, and other sensitive content that could be stolen and used against you.
  • * You may NOT upload files that contain ANY sensitive personal identifying information. If documents contain this information you MUST drop them off at the main office. This includes: - Social Security number - Personal bank account numbers - Passport related information - Credit or Debit Card information - Drivers License of State I.D.
    Drop files here or
    Accepted file types: jpeg, jpg, png, doc, pdf, docx, Max. file size: 512 MB.
    • I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Title 18, Section 1001 of U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent statement to any department or agency of the United States Government.
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    540-434-7386

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    P.O. Box 1071
    Harrisonburg, VA 22803

    Phone: 540-434-7386
    Fax: 540-432-1113

    Quick Links

    • Apply For Housing
    • Online Change in Household Form
    • Online Change in Income Form
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