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Reno Housing Authority
Update Information Form
Directions: Answer all questions as they stand today. Do not report anticipated changes, only
changes that have actually occurred. Do not write “varies,” “on file,” “already reported,” etc. Failure
to provide complete information may result in delays in updating your file and may result in the
termination of your housing assistance. All changes must be reported within 30 calendar days of the
change. If available, please include pay stubs, benefit letters, or other documentation for the change.
Do not delay reporting the change while waiting for supporting documents.
Head of Household Name:
Social Security Number or Client Number: Home Phone:
1. Are you requesting a decrease in your portion of rent based on the changes you are reporting
today?
No Yes
2. Do you anticipate a new source of income starting within 30 days?
No Yes
3. Have there been any changes in the membership of your household? For example: someone
moving out, marriage, divorce, child born, etc. (You must complete an add-a-member form and
receive written approval from the Reno Housing Authority prior to anyone moving into the unit.)
No Yes (provide all information)
Date of change:
Describe change:
4. Is the Head of Household employed (including self-employment)?
No Yes (provide all information)
Employer’s name(s):
Employer’s address:
Date of Hire: Rate of Pay: $ per Hours per week (give a range if varies):
Other [such as tips, meal allowance, bonuses, or overtime] (specify type, amount, and frequency):
This employment is considered: Part-time Full-time
5. Has the Head of Household lost any source of income?
No Yes (provide all information)
Date income lost: Type of income lost:
Name of person/entity supplying income:
Address of person/entity supplying income:
This was a: Decrease of income Total loss of income
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6. Is any other household member employed? (Minor or Adult)
No Yes (provide all information)
Person employed:
Employer’s name(s):
Employer’s address:
Date of Hire: Rate of Pay: $ per Hours per week (give a range if varies):
Other [such as tips, meal allowance, bonuses, or overtime] (specify type, amount, and frequency):
This employment is considered: Part-time Full-time
7. Has any other household member lost a source of income?
No Yes (provide all information)
Person who lost income:
Date income lost: Type of income lost:
Name of person/entity supplying income:
Address of person/entity supplying income:
This was a: Decrease of income Total loss of income
8. Does any household member receive benefits from an outside agency?
No Yes (Check all that apply and complete information for each)
TANF (cash aid) Agency providing assistance:
Amount receiving: $ Start date: End Date:
Food Stamps Agency providing assistance:
Amount receiving: $ Start date: End Date:
General Assistance Agency providing assistance:
Amount receiving: $ Start date: End Date:
Energy Assistance Agency providing assistance:
Amount receiving: $ Start date: End Date:
9. Does any member of your household receive child support payments? (If you receive payments
from multiple sources, please clearly indicate ALL payments received. You may attach a separate sheet
of paper or make a note on the back of this form.)
No Yes (provide all information)
Is this support court ordered? No Yes (If yes, the RHA must have a copy of the order on file.)
Name of child(ren) the payments are for:
Name of person/agency from which you receive payments:
Address of person/agency:
Amount receiving: $ per Start Date: End Date:
10. Is any member of your household (age 18 or over) attending school?
No Yes (provide all information)
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Student Name:
Name of School:
Address of School:
Start Date: Expected Graduation Date:
Part-time Full-time
11. Does any household member receive a pension?
No Yes (provide all information)
Name of person receiving pension:
Name of entity paying pension:
Address of entity paying pension:
Amount receiving: $ Start Date: End Date:
12. Does any household member receive Social Security benefits (SS, SSD, SSI)?
No Yes (provide all information)
Name of person receiving benefits:
Type of benefit (SS, SSD, SSI): Start date:
Amount receiving (before deductions): $
Name of person receiving benefits:
Type of benefit (SS, SSD, SSI): Start date:
Amount receiving (before deductions): $
Name of person receiving benefits:
Type of benefit (SS, SSD, SSI): Start date:
Amount receiving (before deductions): $
13. Does any household member receive unemployment benefits?
No Yes (provide all information)
Name of person receiving unemployment:
Name of entity paying unemployment:
Address of entity paying unemployment:
Amount receiving (before taxes): $ Start Date: End Date:
14. Does anyone outside your household help you pay your bills or pay any of your bills on your
behalf?
No Yes (provide all information)
What is the income/support for?
Name of person/entity supplying income:
Address of person/entity:
Amount receiving: $ per Start Date: End Date:
15. Has any household member had a change in assets (checking account, savings account, IRA,
401k, annuity, stocks, bonds, CDs, whole life insurance, etc.)?
No Yes (Check all that apply and supply requested information)
Opened bank account
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Type (checking, savings, etc.): Account # (last 4 digits):
Bank: Current Balance: $ Interest Rate:
Closed bank account
Type (checking, savings, etc.): Account # (last 4 digits):
Bank:
Sold asset for less than value
Description of asset:
Sale price: $ Value: $
Other (please explain):
16. Has anyone in the household received a lump sum payment?
No Yes (provide all information)
Reason for lump sum (taxes, back pay for benefits, etc.):
Name of person/entity paying lump sum:
Address of person/entity:
Amount received: $ Date received:
What you did with the money (put in bank account, bought items, paid off bills, etc.):
17. Does any household member receive income from any other source?
No Yes (provide all information)
nd
Describe income (2 job, self-employment, family support, etc.):
Name of person receiving income:
Name of person/entity supplying income:
Address of person/entity:
Amount receiving: $ per Start Date: End Date:
18. Has any household member had a change in medical expenses?
No Yes (provide all information)
For households eligible for medical deductions (i.e. elderly and/or disabled families), describe changes:
19. Does any household member pay for childcare?
No Yes (MUST check one of the following boxes and complete entire section)
Childcare allows another in the household to work. (Questions 4 or 6 must be “Yes”)
Childcare allows another in the household to go to school. (Question 10 must be “Yes”)
Childcare allows another in the household to seek employment. (Provide documentation of
seeking work)
Name and age of child(ren) receiving care:
Name of childcare provider:
Address of childcare provider:
Amount paid by household: $ per
Does any person/agency outside of the household pay for the childcare:
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No Yes (complete following section)
Name of person/agency outside of household paying for childcare:
Address of person/agency outside of household paying for childcare:
Amount paid by person/agency outside of household: $ per
By typing my full name below, I acknowledge my understanding of the following:
I certify that the information given to the Reno Housing Authority (RHA) on family composition and characteristics,
drug and criminal activity, income, assets, and expenses, is accurate and complete. I understand that false
statements or information are punishable under Federal Law and grounds for denial or termination of housing
assistance. I understand that I am required to report in writing to RHA all changes in family composition, income,
assets, and expenses of any family member(s) within thirty (30) days of the change. Further that no one is
permitted to move into my unit without prior written approval of RHA and my landlord. I understand that any
misrepresentation of information or failure to disclose information requested on this declaration may disqualify
me from participation and may be grounds for eviction or termination of assistance.
I understand that any attempt to obtain Public Housing, any rent subsidy or rent reduction by false information,
impersonation, failure to disclose or other fraud and any act of assistance to such attempt is a crime under Title 18,
Section 1001 of the U.S. Code that states a person is guilty of a felony for knowingly and willingly making false or
fraudulent statements to any Department or Agency of the United States.
E-Signature of Head of Household: Date:
E-Signature of Spouse or Co-Head: Date:
E-Signature of Other Adult: Date:
Address of Household:
Home Phone: Cell Phone:
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