Income Change Request Form - HA Property

Phone: 805-736-3423 | Fax: 805-735-7672
815 West Ocean Avenue, Lompoc, CA 93436
hasbarco.org

Please fill out the form below if you have experienced a loss or change in income. A staff member will reach out to you as soon as possible. Please include as much detail as possible.

* = required fields.

Please submit online or print the completed form with supporting documentation and drop off at any of our drop box locations listed below:

Santa Maria

Evans Park -

200 W Williams St

Central Plaza -

200 N McClelland St Rancho

Hermosa -

235 E Inger Dr

Goleta

Housing Office -

5575 Armitos Ave

Sandpiper Apartments -

375 Ellwood Beach Dr

Positano Apartments -

11 Camino De Vida

Pescadero Lofts -

761 Camino Pescadero

Lompoc

Administration -

815 W Ocean Ave

Housing Office -

817 W Ocean Ave

Lompoc Terrace -

904 W Walnut Ave

Parkside Gardens -

240 W Pine St

Homebase on G -

513 North G St

Cypress Court -

125 South 7th St

Creekside Village -

260 Gonzales Dr, Los Alamos

Tenant First Name *

Tenant Last Name *

Social Security Number *

Date of Birth *

Phone Number *

Email *

Email Confirmation*

Are you an FSS Participant? *

Specialists Name (if known)

Unit Address *

Please Select Property Name *

Lompoc Properties *

Santa Maria Properties *

Goleta Properties *

Reason For Request *

Decrease of Income Attach Supporting Documentation: Termination Letter from Employer OR Letter from employer, reduced rate of pay, hours per week and starting date. OR Last Paystub with notation of changed hours/income.

Increase of Income (New Job)

Name of Employer *

Address of Employer *

Employer Phone Number *

Employer Email

Employer Fax Number

Attach Supporting Documentation: Letter from employer, stating rate of pay, hours per week and starting date. Last Paystub.

Change in Current Employment (Raise, Shift Differential, Bonus, etc.)

Type of Change *

Name of Employer *

Address of Employer *

Employer Phone Number *

Employer Email

Employer Fax Number

Increase/Decrease of Income Benefits

Benefit Increased/Decreased *

Other Benefit *

Attach Supporting Documentation: Award letter

Adding/Removing an Adult (18+) Household Member

Name of Household Member *

Adding a Minor Household Member Attach Supporting Documentation: Birth Certificate & Social Security Card

Removing a Minor Household Member

Name of Minor Household Member *

No Longer a Full-Time Student

Student Name *

School Name *

Attach Supporting Documentation: Unofficial Transcripts

Becoming a Full-Time Student

Full Time Student Name *

Full Time Student School Name *

Attach Supporting Documentation: Financial Aid & Unofficial Transcript

In Kind Income (Family/Friend Support)

Amount Frequency *

Weekly

Monthly

Dollar Amount *

I certify under penalty of perjury that I receive [$x] per [frequency] *

Child Support Increase/Decrease Please login to the California Department of Child Support Services online portal at https://www.cse.ca.gov/CustomerConnect/login, print the 12 month summary of the payments that you have received, then attach it here.

Supporting documentation is not required to submit this form but documentation will be required during the verification process. If documentation is submitted with the form, the verification process will move faster. * I understand that if supporting documentation for the reported change is not submitted with this request it may delay this process.

The reported change will be effective on the first day of the next month.

I Declare and Say:

I certify under penalty of perjury that the reported change(s) are true and correct and any additional changes will be reported immediately.

Signature *

Date of Signature *

HACSB USE ONLY

Date of Request (HACSB USE ONLY)

T Code (HACSB USE ONLY)