Interim Recertification Change Report Form (HUD)

Tenant form to report a mid-year change in income or household composition for interim recertification review under HUD program rules.

Submission Notice and Consent

• I understand this form is for reporting a mid-year change that may affect my rent, eligibility, or household composition.
• I consent to the housing provider reviewing the information and documents I submit for interim recertification processing.
• Preferred contact method

Tenant Information

• Tenant full name
• Unit number
• Property or site name
• Phone number
• Email address

Reported Change Type

• What type of change are you reporting?
• Brief summary of the change
  Describe what changed and when it occurred. Do not include unnecessary personal details.
• Date the change took effect

Income Change Details

• Household member affected
• Type of income source
• Did the income change increase or decrease?
• Current gross monthly income
  Enter the current monthly amount if known. Do not include account numbers or tax IDs.
• Reason for the income change

Household Composition Change Details

• Describe the household change
• Was a person added or removed from the household?
• Relationship to tenant
• Move-in or move-out date

Supporting Documentation

• Supporting documents
  Examples: pay stubs, employer letter, benefit award letter, birth certificate, death certificate, custody order, or move-out notice.
• Document notes
  Explain what each document shows and whether any information has been redacted.

Certification and Submission

• I certify that the information provided is true and complete to the best of my knowledge.
• Electronic signature
• Date signed