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Job Loss Form

Use this form to report a job loss.

Full Name
First and Last
  • {name}
Reason
If Other Reason
  • {name}
Employer Name & Address
  • {name}
Case Manager
Applied for Unemployment
Check if you applied for unemployment
Enter Unemployment Monthly Benefit Amount
True and Complete
I Certify This Form Is True and Understand Filing A False Form Will Cause A Forfeiture Of My Housing Benefits. Please be advised while we are here to serve you. Regulations authorize a public housing authority to terminate benefits when a family engages in or threatens abusive or violent behavior toward the authority’s personnel [24 CFR § 982.552(c)(1)(ix.)]WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any department or Agency of the United States as to any matter within its jurisdiction. Check the box to certify your understanding and compliance.
If you don't receive a response within 7 days - You must resubmit this form -

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