COVID-19

Date*

Enter today's date.

Program*

HCV (Section 8)

LIPH (Low Income Public Housing)

Development Name*

Select the name of your property from drop down list. You may add your development property if you do not see it.

Select or enter value

HOH Last Name*

Enter the head of household's last name.

HOH First Name*

Enter the head of household's first name.

Address*

City*

Zip Code*

Phone Number*

Household Member Impacted 1*

Enter the name of the household member whose income has decreased due to the COVID-19 closures. Enter the members full name.

Employer 1*

Name of employer

Pay Rate*

Hourly rate

Current Hours Worked1*

Number of hours currently working per week.

Name of Household Member Impacted 2

Please enter the name of a second household member whose income has decreased or if a second source of income has been decreased for household member 1.

Employer 2

Name of employer

Pay Rate 2

Hourly rate

Current Hours Worked 2

Number of hours currently working per week.

Name of Household Member Impacted 3

Please enter the name of a third household member whose income has decreased or if a second source of income has been decreased for household member 1 or 2.

Employer 3

Name of employer

Pay Rate 3

Hourly rate

Current Hours Worked 3

Number of hours currently working per week.

Signature*

By typing your name in the text box below you are electronically signing that the information on this form is true to the best of your knowledge.

File Attachments

If you received a letter from your employer stating your hours reduction due to COVID-19, attach the document.

Drag and drop files here or

Send me a copy of my responses

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