Change of Income or Family Status Form AND Hardship Request Form

Use this form to submit a change of income or family status. If you are receiving an error when trying to submit your form, try a different browser (Google Chrome, Firefox, etc.) or using a different computer/device.

This form is NOT for requesting a minimum rent hardship. If you need to request a minimum rent hardship, please complete the form sent to you by your certification specialist.

Please allow up to 30 days to process your request.

Documentation of any change must be attached in order to process your request.

Have you turned in any other COFS or Income Change that has not been completed or Timely Report letter received?

Today's Date

mm/dd/yyyy

Program Type

Where do you live?

Address

Head of Household Last 4 SSN

Head of Household First Name

Head of Household Last Name

Phone Number and Email Address

Did you have an INCOME INCREASE - please mark the type of income that has changed below and complete all information for that section.

Did you have an INCOME DECREASE - please mark the type of income that has changed below and complete all information for that section

Did you experience a loss in income due to COVID-19/coronavirus?

Did you have a change in Employment?

For job loss: provide a letter from your employer with end date.

For new job: provide a letter from your employer with start date, rate of pay, and hours worked per week.

For an increase/decrease in wages: provide 3 current and consecutive pay stubs.

Did you have a change in Unemployment?

Provide a screenshot or award letter of your unemployment benefits including start date and weekly amount: https://unemployment.cmt.ohio.gov/cmtview/loginc.jsp

Are you waiting on an unemployment determination?

Did you have a change in TANF/OWF/Cash Assistance?

Provide a letter from DJFS with start/end date and monthly benefit amount, if applicable.

Did you have a change in Social Security?

Provide a letter from Social Security with start/end date and monthly benefit amount.

Did you have a change in Child Support?

Provide a 12 month print-out from CSEA's website: https://jfs.ohio.gov/Ocs/CustServWebPortalWelcome2.stm

Did you have another change that is not listed above?

Due to this change is an adult in your household now at zero income?

Are you paying for childcare for anyone in your household under age 13?

Provide receipts or other proof of amount paid.

Do you have 6 or more dependents (children, disabled adults) in your household?

Has an adult in your household newly become a full-time student?

No change is needed if head of household, cohead, or spouse becomes a full-time student.

Provide a current school schedule with credit hours listed.

Do you need your rent portion to be lowered for some other reason not listed above? (such as a death in the family or a large out-of-pocket medical expense)

Provide proof of your hardship.

Is the head of household, co-head, or spouse elderly (62 or older), handicapped, or disabled AND will be paying medical expenses?

Including but not limited to: Medicare, pharmacies, doctor visits, dentist, medical insurance providers, hospitals bills which you are paying on, or other related medical expenses.

Do you need to add or remove someone from your household?

Are you a participant on the Tiered Rent program?

Tiered Rent participants have completed an enrollment interview and been told by AMHA staff that they have been assigned to tiered rent.

Tiered Rent participants must provide ALL of their household's income with this form. If proof of ALL income is not included, your change will be denied.

Please upload documentation supporting your requested income change. Examples: Paystubs, Layoff Notification, Benefit change letter. Please note, changes cannot be completed without proper supporting documentation. Failure to submit proper documentation may delay the income change.

Drop your files here

If you did not attach proof of your change, please explain why you could not (Work Number employer, etc.)

If you are unable to upload supporting documentation with the submission of this form:

Your documentation must be provided to our office within 10 days of submitting this change request.

By marking yes and signing below, you acknowledge receipt of this notice that supporting documentation is required.

Tiered Rent Households -

If you are part of AMHA’s tiered rent program, you must provide proof of ALL of your household’s current income with this form. Due to the tiered rent program rules, you do not have an additional 10 days to provide documentation as stated above. AMHA cannot process your request without this information. If you do not provide proof of your hardship/change marked above AND proof of all of your current income, your hardship request will be denied and you will have to request a hardship again when you have the proof that is required.

Electronic Signature - Type your FULL NAME

By entering your name in the box below you are electronically signing this form and certifying that the information given above is accurate and complete to the best of your knowledge and belief. You understand that providing false information is punishable under Federal and State law and is grounds for termination of your housing assistance.

Please review the Electronic Signature line above. Does your FULL NAME show?

If no, please re-type your name on the Electronic Signature line.

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