Verification of Welfare Benefits

Poinsett County DHS
406 North Illinois
Harrisburg, AR, 72432

Re:

Date

Social Security No

Other Family Members on Lease

We are required to verify the income of all applicants and participants in the federally-assisted housing programs operated by the Housing Authority. We ask for your cooperation in supplying the information listed below:

Housing Authority Representative

Telephone

I do hereby authorize the Department of Human Services to furnish the Housing Authority with the information requested above. I also grant the PCHA permission to furnish the Department of Human Services with information regarding my file.

Signature

Date

TEA

Monthly Benefit Amount Before Sanction($)

Monthly Benefit Amount After Sanction($)

Sanction Date

Term of Sanction

Reason for Sanction

SNAP

Monthly Benefit Amount($)

Effective Date

Do you have any information of any income from other sources for the person(s) listed, or anyone living in the household who is not listed on this page? If Yes, please list below. (If wages, please name the employer)

Yes
No

From

For (Name)

From

For (Name)

Number of Minors in Family

Remarks from DHS to PHA

Completed By

Date

Name (please print)

Telephone No

If you are disabled or have difficulty understanding English, please request our assistance and we will ensure that you are provided with meaningful access based on your individual needs.

Si usted es desactivar o tiene dificultad para entender Ingles, por favor solicite neustra ayuda y nos aseguramos de que se le proporciona un acceso significativo basado en sus necesidades individuales.

Haddii aad tahay wuxuu curyaamin ama ay ku adag tahay fahamka Ingiriisi, fadlan codsato gargaarka oo aan loo hubiyo in aad waxaa la siiya helaan macno leh oo ku salaysan baahiyahaaga shaqsi.

PLEASE RETURN TO: Poinsett County Housing Authority, 1104 Elm Street, Marked Tree, AR 72365 OR
FAX TO: (870) 358-4537