Home >>

ALBEMARLE COUNTY RENTAL ASSISTANCE PROGRAM

Client Information Change/Update Form


INSTRUCTIONS: Please complete the following form AS THOROUGHLY AS POSSIBLE. If you select a change to be made but do not enter any information in the appropriate section, your changes will not be transmitted until you make the necessary corrections. If you provided an email address on this form, you will be sent an email confirmation once the information has been successfully been transmitted. It is your responsibility to contact the Office of Housing within a few days to make sure your changes were received and accepted.

Fields with * are REQUIRED. Other fields may be REQUIRED depending on specific changes to be made.

*Office of Housing CLIENT:              Wait List APPLICANT:
*NAME:  First Name      Last Name
 
CURRENT CONTACT INFORMATION:

*Street


*City, State, Zip ,   
*Current Phone(s)
AAA-NNN-NNNN (at least one required)
 Home      Work      Cell
Email Address:
If you provide an email address, you will receive an acknowledgment of your changes to this address.
 
*HOUSING SPECIALIST:  
 
*CHANGES TO BE MADE: (please select all that apply)
  Household Size       Employment/Income       Assistance/Benefits       Other Changes

HOUSEHOLD CHANGES

NAMES TO BE ADDED:
1.  Age:  Does this person have income? Estimated Annual Income if applicable: $
Enter numbers only, no$ or commas
2.  Age:  Does this person have income? Estimated Annual Income if applicable: $
Enter numbers only, no$ or commas
3.  Age:  Does this person have income? Estimated Annual Income if applicable: $
Enter numbers only, no$ or commas
4.  Age:  Does this person have income? Estimated Annual Income if applicable: $
Enter numbers only, no$ or commas
5.  Age:  Does this person have income? Estimated Annual Income if applicable: $
Enter numbers only, no$ or commas
 
Names to be DELETED
1.  Age: 
2.  Age: 
3.  Age: 
4.  Age: 
5.  Age: 
Number of Persons in Household after Changes (INCLUDING ALL PERSON(S) LISTED ABOVE)  

CHANGE IN EMPLOYMENT/INCOME

I am no longer working at my previously reported job.

Last Date of Employment:  

 I have started a new job.
Employer's Name:
Employer's Address:
Employers City, State, Zip ,   
Employer's Phone Number:    Employer's Fax Number:  (if any)
Wages/Salary: $  per
Enter numbers only, no$ or commas
Hours Worked Per Week: 
Date Started:
 

 I am working at the same job with the following changes:
   The number of hours worked per week changed from  hours per week to  hours per week.
 
   The hourly wages/salary changed: FROM $    per  Enter numbers only, no$ or commas
    TO: $    per  Enter numbers only, no$ or commas

ASSISTANCE/BENEFITS  

Please list any changes in public assistance (TANF, food stamps, daycare, etc.) and any changes in alimony and/or child support payments:

(Maximum 1000 characters)

 
OTHER CHANGES

Please list any changes not included above (example: childcare costs, etc.)

(Maximum 1000 characters)
 

*ALL CLIENTS

The statements made by me in this application are true and complete to the best of my knowledge. I understand that willful misstatements or material omissions on this application will be sufficient cause to invalidate my Rental Assistance Voucer with Albemarle County, VA.

I understand that this completed application and any materials submitted with it are the property of Albemarle County, VA, and will not be returned.

I authorize Albemarle County, VA, to investigate the information contained in this application and I hereby release employers, schools, or other persons from all liability in responding to inquiries concerning my application.

I understand that information collected, maintained, used and disseminated by the County through the use of this electronic form shall be limited to only that personal information permitted or required by law to be so collected, maintained, used or disseminated, or necessary to accomplish a proper purpose of the County, and the County will comply in all other respects with the requirements of the Government Data Collection and Dissemination Practices Act, Va. Code section 2.2-3800, et seq. as amended. Should I wish to review the contents of my application, I may do so by submitting a written request to the County of Albemarle Office of Housing. Upon receipt of such request, an authorized member of the County of Albemarle Office of Housing will provide a printed version of the information contained in my personal file.

Date Applied: 10/18/2017 9:14:15 AM

*SIGNATURE (Please type your FULL LEGAL NAME):

        

Return to Housing Site


Admin Only Login